2024 Volume 6 Issue 12 Pages 598-599
A 49-year-old woman was admitted to our hospital with intermittent claudication. She had sudden onset of bilateral lower limb weakness and numbness while jogging approximately 2 months earlier. The symptoms gradually ameliorated and she could then walk and go home. There were no cardiovascular risk factors (i.e., hypercholesterolemia, diabetes, or smoking history), and no malignancy. Ultrasonography (Figure A) and contrast-enhanced computed tomography (Figure B) revealed thrombotic stenosis of the lower abdominal aorta to the bilateral common iliac arteries. Laboratory data did not show dyslipidemia, antithrombin deficiency, protein C or protein S deficiency, antiphospholipid syndrome, or vasculitis. The transthoracic echocardiography results were normal. Aortography revealed stenosis at the same region (Figure C). Intravascular ultrasonography confirmed thrombotic stenosis without atheroma or dissection (Figure D). Transesophageal echocardiography revealed a patent foramen ovale (PFO) and the microbubble test result was positive (grade III; Figure E). Ultrasonography showed no deep vein thrombi. Brain magnetic resonance imaging revealed small cerebral infarctions (in the right cerebellum and frontal lobe) with normal vessels, suggesting thromboembolism (Figure F).
(A) Ultrasonography of the aorta (A-1), and common iliac arteries (A-2). (B) Contrast-enhanced computed tomography of the aorta to common iliac arteries (transverse section of ① [B-1], and ② [B-2]). (C) Aortography. (D) Intravascular ultrasonography. (E) Transesophageal echocardiography of the PFO (arrow), and microbubbles (arrowheads). (F) Brain magnetic resonance imaging (diffusion-weighted imaging). LA, left atrium; PFO, patent foramen ovale; RA, right atrium.
She was finally diagnosed with acute limb ischemia (ALI) due to PFO-mediated paradoxical aortic and bilateral iliac thrombi because no other cause could be found. Although ALI due to PFO-mediated paradoxical embolism is rare,1 thrombi in the aorta and arteries of the lower limbs without atherosclerosis or arteritis should be considered.
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The authors have no conflicts of interest or funding to declare. K.M. is a member of Circulation Reports’ Editorial Team.
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