Paradoxical embolism as a type of thrombembolism originating in the venous vasculature traversing into systemic circulation requires a right-to-left shunt, such as a patent foramen ovale. This condition has a diverse clinical presentation depending on the vascular beds affected and the amount of the clot present. We don't know its true prevalence, but we know it can be life threatening. The diagnosis requires high degree of suspicion and the success of treatment often depends on the prioritisation and holistic principles.

Case report

Case presentation: We present a case report of 67 year old, otherwise healthy man, who presented with a sudden onset of lower extremity paraplegia due to distal aortic embolisation, also small renal emboli and brachial embolism and concomitant sub-massive pulmonary embolisation confirmed on CT Angiogram. This was a case of paradoxical embolisation or combination of systemic arterial and pulmonary embolism in the presence of patent foramen ovale. No echocardiography signs of cor pulmonale was present , but it revealed a type A clot-in-transit phenomenon, mentioned more descriptively in the echocardiography report, rather than correctly named or emphasised. Our initial dilemma was mainly in regards to adding pulmonary embolectomy to aortic embolectomy with an absence of typical clinical signs of massive PE, but with some fluctuation in haemodynamic stability, limited ECMO access should this be needed, presence of clot-in-transit and foramen ovale patency. We decided to perform both pulmonary and aortic embolectomy simultaneously followed by brachial embolectomy. This was achieved within 7-8 hours from the onset of symptoms and the patient recovered well, without secondary complications and with excellent functional state having been restored.

Discussion: We reviewed literature on the controversy of surgical pulmonary embolectomy in these rare clinical scenarios, its justifications and also its safety and the results. We are also discussing added benefit of surgical pulmonary embolectomy in the presence of clot-in-transit through the right heart chambers and the patent foramen ovale. We observed low awareness of the clot-in transit phenomenon not only among vascular surgeons but also among interventional radiologists and cardiologists in our institution. The decision making is often very complex  and multidisciplinary. It also needs to be made urgently, without existence of robust and easy-to-follow guidelines. The purpose of our report mainly is to raise the awareness of some specific and often complex aspects of the treatment of the paradoxical embolisation.

1, Surgical Pulmonary Embolectomy, Timothy J. Poterucha, MD; Brian Bergmark, MD; Sary Aranki, MD; Tsuyoshi Kaneko, MD;Gregory Piazza, MD, MS 2, Surgical Embolectomy for Acute Pulmonary Thromboembolism, Ikuo Fukuda, MD, PhD and Kazuyuki Daitoku, MD, PhD 3, Right heart thrombus in transit: a series of two cases, Eva Otoupalova , Bhavinkumar Dalal2 and Brian Renard3