Case Reports Systemic Thrombolysis Using Tissue Plasminogen Activator for a Patient With Paradoxic Embolism:

Doppler study of the lower extremities demon-strated an acute thrombus involving the left superfi-cial femoral, deep femoral, and greater saphenous veins with spontaneous and phasic flow in the common femoral vein. Carotid artery duplex scan showed no Case Report The patient is an 82-year-old female with a history of deep vein thrombosis (DVT) who presented with profound dyspnea for 3 days. The patient also noticed left arm paresthesia. On physical examina-tion, she had decreased breath sounds and required 3 L oxygen via nasal cannula to keep the oxygen sat-uration above 90%. Blood pressure was not obtain-able on the left side. The left brachial and radial pulses were absent. The left hand was cool, but there were no motor or sensory deficits. There was a Doppler signal on the left radial artery. Computed tomography (CT) of the chest demonstrated large pulmonary emboli in the main pulmonary arteries bilaterally, with thrombus in the origin of the left subclavian artery with a clot extend-ing into the descending thoracic aorta, and throm-bus at the origin of the celiac artery with associated infarcts in the spleen (Figures 1-4). When thrombotic material that originates from deep venous thrombosis of the lower extremities is washed out into the pulmonary vasculature, pulmonary emboliza-tion occurs. Pulmonary embolism and associated acute peripheral ischemia suggest the diagnosis of paradoxic embolism, which is most often associated with a patent foramen ovale. Therapeutic options include anticoagulation, mechanical/chemical throm-bus dissolution, inferior vena cava filtration, and closure of the intracardiac defect. The diagnosis and treatment are described of an elderly female who pre-sented with lower extremity deep venous thrombosis and massive pulmonary embolism complicated by paradoxic emboli to the left subclavian artery as well as the celiac artery