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Published on: October 25, 2024
Pulmonary Embolism, Silent Stroke, and an Occult Caval Thrombus: 1 Clot, 3 Territories
Truong Q Le1, Nhat M Giang1, Hai H Nguyen1
1Department of Intensive Cardiovascular Care and Cardiovascular Imaging, Nhan dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam.
Background:
Clot in transit (CIT) through a patent foramen ovale (PFO) with concomitant pulmonary embolism is a rare condition that carries high mortality and lacks established management guidelines.
Case Summary:
A 67-year-old woman presented with 5 days of exertional dyspnea. Echocardiography showed a mobile thrombus traversing the atrial septum through a PFO with right ventricular dysfunction. Computed tomography pulmonary angiography demonstrated a saddle embolus, and brain imaging revealed a clinically silent paradoxical infarct. Compression ultrasonography showed no deep vein thrombosis. During emergency embolectomy with PFO closure, an unsuspected inferior vena cava thrombus was retrieved.
Discussion:
CIT requires direct assessment of the pulmonary, systemic arterial, and venous axes before reperfusion is selected; computed tomography pulmonary angiography does not reliably assess the inferior vena cava.
Take-Home Message:
When CIT is identified, interrogate the caval axis directly rather than inferring it from a negative pulmonary angiogram.
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