The complicated journey of a thrombus: from the peripheral veins to the renal artery

Introduction: Embolic events frequently have a cardiac source (cardio-embolism) and affect the cerebrovas-cular circulation, ending-up in stroke of different degrees of severity. More rarely, cardio-embolism causes arterial occlusions in other territories (splenic, renal, mesentery arteries, peripheral arteries, etc). The main cause of the cardio-embolism is atrial fibrillation with left auricular thrombosis. Mitral stenosis, atrial myxo-mas, endocarditis, left ventricular trombi and pros-thetic thrombosis may be causes for cardiac embolic events, as well. Arterial occlusion due to thrombi from the venous system (deep vein thrombosis) can occur as a paradoxical embolic event, in which a venous throm-bus passes from the right to the left cardiac circulation through a cardiac communication, such as atrial septal defects (ASD) or foramen ovale patent (FOP). Our case shows a rare case of acute thrombotic renal occlusion of the left renal artery in a middle-aged pa-tient without atherosclerotic lesions detectable on an-giography. Ultrasonography indicats deep vein throm-bosis of the left lower limb and large patent foramen ovale, with passing of an increased amount of contrast from the right to the left circulation at the „bubble test“, suggesting a paradoxical embolism.

Case presentation: A 60-year-old man with no significant medical history presents to the emergency room for acute abdominal pain. Symptom onset was 48 ho-urs prior to presentation. Clinical examination, ECG, blood tests and abdominal ultrasound are unspecific. Transthoracic echocardiography reveals enlargement of left atrium and interatrial septal aneurysm. Emer-gency thoraco-abdominal computed tomography reveals acute thrombotic occlusion of the left renal artery and multiple renal infarctions. Emergency angiography confirms thrombotic occlusion of the left renal artery and thrombus aspiration is performed with partial recovery of renal arterial flow. Venous Doppler ultrasound shows direct signs of thrombosis in the left common and superficial femoral vein. Holter ECG monito-ring does not show episodes of atrial or ventricular arrhythmia. Transesophageal echocardiography reveals large foramen ovale patent with right-to-left passing of an increased amount of contrast at the agitated saline contrast injection. After 3 months of oral anticoagulati-on, closure of the foramen ovale patent with Amplatzer occluder is successfully performed.

Particularities: The particularity of the case is the late onset of paradoxical embolism due to a large PFO in 60-years old patient and the rare localization of the embolism in renal arterial tree. To obtain a complete diagnosis, an extensive imaging examination of the patient was required, both invasive (emergency angi-ography) and non-invasive (thoraco-abdominal com-puted tomography, abdominal and venous ultrasound, transesophageal and transthoracic echocardiography). Another particularity of the case is the complex inter-ventional management of the case. In the acute phase we performed thrombus-aspiration followed by conti-nuous iv un-fraction heparin for 7 days. After 3 months of direct oral anticoagulation, patient underwent per-cutaneous closure of the PFO with insertion of an Amplatzer device in order to prevent recurrent paradoxical embolic events.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)