eMedicine Specialties > Vascular Surgery > Medical Topics

Paradoxical Embolism: Follow-up

Author: Igor A Laskowski, MD, Assistant Professor of Surgery, Section of Vascular Surgery, New York Medical College, Westchester Medical Center
Coauthor(s): Sateesh C Babu, MD, Professor of Clinical Surgery, New York Medical College; Associate Director, Vascular Surgery, Co-chief Endovascular Surgery, Westchester Medical Center, Valhalla NY; Oladayo Osinuga, MD, Attending Physician, Department of Internal Medicine, Atlanta Medical Center; Maurice Rachko, MD, FACC, FACP, Director of Coronary Care Unit, Brooklyn Hospital Center; Clinical Assistant Professor, Department of Medicine, Weill Medical College of Cornell University; Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital; Nelson Menezes, MD, RVT, Chief of Vascular Surgery, Assistant Professor, Department of Surgery, Division of Vascular Surgery, The Brooklyn Hospital Center and Cornell University
Contributor Information and Disclosures

Updated: Sep 17, 2009

Follow-up

Further Inpatient Care

  • Inpatient care for people with paradoxical embolism (PDE) depends on their hemodynamic stability and associated presenting clinical manifestations, such as PE, TIA, acute arterial embolism, or debilitating neurological deficits, that may warrant intensive care or regular monitoring.
    • Safety precautions and fall prevention when the risk for falls and safety concerns are present, especially in elderly patients.
    • Aspiration prophylaxis is paramount in patients who are bedridden with minimal or no cough reflex.
    • Neurologic watch is needed to monitor any further neurologic deficit to intervene before further deterioration.
    • Intensive care monitoring is needed in the presence of hypotension and when the patient needs vasopressors, intubation, and mechanical ventilation.
    • Pain management is needed in patients with acute arterial limb occlusion that commonly presents with severe pain and pain associated with DVT.
    • Gastrointestinal prophylaxis is needed to prevent stress ulcers in the presence of cerebral insult.
    • Skin care may involve frequent turning and protective skin devices to prevent skin breakdown and eventual decubitus ulcer.

Further Outpatient Care

  • Outpatient care for paradoxical embolism (PDE) is based on evidence of idiopathic venous thrombosis, hypercoagulable states, PE, the risk-determined DVT, and the sequelae of the clinical manifestation.  
    • Chronic anticoagulation therapy with warfarin may be used for 6 months in DVT/PE or as lifelong therapy with monitoring of the INR in the presence of hypercoagulable states.
    • Chronic antithrombotic therapy with antiplatelet drugs is needed for patients with history of TIA.
    • Physical therapy is needed for patients who will benefit from physical rehabilitation.
    • Visiting nurse may be highly beneficial for monitoring INR at home and helping patients in the administration of subcutaneous injection of LMWH when used for long-term anticoagulation for eventual self-administration.

Inpatient & Outpatient Medications

  • Anticoagulation
    • Warfarin
    • Enoxaparin
    • Tinzaparin
  • Antiplatelet therapy
    • Dipyridamole/aspirin (Aggrenox)
    • Clopidogrel (Plavix)
    • Ticlopidine (Ticlid)
  • Thrombolytics, eg, alteplase (tPA)

Transfer

  • Intensive care unit: Patients with paradoxical embolism (PDE) can be transferred to medical or surgical intensive care units in the presence of hemodynamic compromise.
  • Subacute rehabilitation facility: This may be beneficial in patients with significant neurological deficits and with no further risk of emboli.

Deterrence/Prevention

Prevention remains controversial. Whether or not prophylaxis of persons with a recognized predisposition for paradoxical embolism (PDE) is beneficial and whether patients with hypercoagulable states should be screened routinely using contrast echocardiography for PFO or ASD are not established.

Complications

  • Neurologic deficit as a manifestation of stroke
  • Hemiplegia
  • Amaurosis fugax with eventual blindness
  • Motor aphasia
  • Seizure disorder complicating a cerebral insult
  • Arrhythmia such as ventricular tachycardia/fibrillation in cases of impending paradoxical embolism (PDE)
  • Acute myocardial infarction
  • Loss of limb function with amputation
  • Organ damage, eg, renal infarction
  • Death

Prognosis

  • Prognosis of paradoxical embolism (PDE) is good when it is not complicated.
  • Prognosis of paradoxical embolism (PDE) is poor when it is complicated by PE. When impending paradoxical embolism (PDE) occurs, the choice of treatment involves open-heart surgery.

Patient Education

  • Patients on long-term anticoagulant therapy should be compliant with their medications to prevent recurrent thrombolic events; emphasize compliance.
  • Avoid vitamin K–containing foods such as green leafy vegetables, including spinach, broccoli, and cauliflower.
  • Varicose veins coexist commonly with cyanotic congenital heart disease, and these may predispose to thromboembolic phenomena. These patients should avoid passive standing, should avoid crossing their legs when sitting, and should not allow their legs to be dependent.
  • Avoid Valsalva maneuvers to prevent elevation of the right atrial pressure above the left atrial pressure, which can lead to transient right-to-left shunting in patients with risk factors for paradoxical embolism (PDE).
  • For excellent patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education article Blood Clot in the Legs.

Miscellaneous

Medicolegal Pitfalls

  • The clinical presentation of paradoxical embolism (PDE) is nonspecific. Therefore, paradoxical embolism (PDE) is a diagnostic challenge that is prone to misdiagnosis, which may result in medicolegal action by the patient and family. Paradoxical embolism (PDE) mimics other diseases, and suspicion should be high in order to avoid medicolegal implications.
  • Outcome may be devastating with complications such as neurological deficits, blindness, gangrene of extremities, and amputation, depending on whether the limb is salvageable or not. Organ damage may include renal infarction with eventual renal insufficiency.
  • Adverse reactions from intravenous contrast agents may occur in studies such as venography, arteriography, angiography, and cardiac catheterization. Obtaining an informed consent with full explanation about the indications, implications, and complications of the procedure and the possibility of contrast-associated adverse reactions is important.
  • Appropriate treatment can lead to morbidity and mortality. Thrombolytic treatment can lead to intracranial hemorrhage with extensive neurologic deficits. Transcatheter closure of PFO may lead to residual shunting due to malalignment of the occluder device; this can cause recurrent strokes.
  • Surgical intervention, in the form of embolectomy and closure of PFO, in the presence of intracardiac embolus and PFO has a survival rate of 75% and death rate close to 25%. In view of all the complications of treatment, the benefits should be weighed against the risks. To avoid medicolegal pitfalls, patients and their families should be provided with a thorough explanation about the outcome of the intervention.

Special Concerns

  • Paradoxical embolism (PDE) is not common in pediatric age groups.
  • Paradoxical embolism (PDE) in pregnancy is rare but possible because of increased risk of DVT. Noninvasive modalities should be chosen over an invasive workup, and the treatment is mainly conservative in nature. Heparin is the anticoagulant of choice; the other anticoagulants and thrombolytics are contraindicated. The eventual treatment of choice depends on the trimester of the pregnancy and the assessment of risks versus benefits of treatment.
  • Paradoxical embolism (PDE) in elderly patients is significant because of the associated morbidity and mortality in this age group. Noninvasive and less invasive procedures may be preferable. The risk of falls in elderly persons may make inferior vena cava interruption a better choice than warfarin for long-term anticoagulation when DVT and PE are present in paradoxical embolism (PDE).
 


More on Paradoxical Embolism

Overview: Paradoxical Embolism
Differential Diagnoses & Workup: Paradoxical Embolism
Treatment & Medication: Paradoxical Embolism
Follow-up: Paradoxical Embolism
Multimedia: Paradoxical Embolism
References
Further Reading
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References

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Further Reading

Clinical guidelines
Deep venous thrombosis.
Finnish Medical Society Duodecim - Professional Association.  2001 Apr 30 (revised 2006 Apr 27).  Various pagings.  NGC:004983

Guidelines on the diagnosis and management of pericardial diseases. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology.
European Society of Cardiology - Medical Specialty Society.  2004 Jan.  28 pages.  NGC:003524

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
Global Initiative for Chronic Obstructive Lung Disease - Disease Specific Society
National Heart, Lung, and Blood Institute (U.S.) - Federal Government Agency [U.S.]
World Health Organization - International Agency.  2006 (revised 2007).  109 pages. [NGC Update Pending] NGC:006275

Clinical trials
PC-Trial: Patent Foramen Ovale and Cryptogenic Embolism

Risk of Stroke in Pulmonary Embolism With a Patent Foramen Ovale (PFO)

Related eMedicine topics

 Patent Foramen Ovale

Atrial Septal Defect, Patent Foramen Ovale

Venous Air Embolism

Pulmonary Embolism

Deep Vein Thrombosis, Lower Extremity



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Keywords

paradoxical embolism, PDE, deep vein thrombosis, DVT, deep venous thrombosis, PFO, patent foramen ovale, thromboembolic disease, embolism

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Contributor Information and Disclosures

Author

Igor A Laskowski, MD, Assistant Professor of Surgery, Section of Vascular Surgery, New York Medical College, Westchester Medical Center
Igor A Laskowski, MD is a member of the following medical societies: American College of Surgeons, American Hepato-Pancreato-Biliary Association, Peripheral Vascular Surgery Society, Society for Vascular Surgery, and Transplantation Society
Disclosure: Nothing to disclose.

Coauthor(s)

Sateesh C Babu, MD, Professor of Clinical Surgery, New York Medical College; Associate Director, Vascular Surgery, Co-chief Endovascular Surgery, Westchester Medical Center, Valhalla NY
Sateesh C Babu, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Institute of Ultrasound in Medicine, American Medical Association, Eastern Vascular Society, International Society of Endovascular Specialists, New York Academy of Sciences, Royal Society of Medicine, Society for Vascular Surgery, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Oladayo Osinuga, MD, Attending Physician, Department of Internal Medicine, Atlanta Medical Center
Oladayo Osinuga, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association
Disclosure: Nothing to disclose.

Maurice Rachko, MD, FACC, FACP, Director of Coronary Care Unit, Brooklyn Hospital Center; Clinical Assistant Professor, Department of Medicine, Weill Medical College of Cornell University
Maurice Rachko, MD, FACC, FACP is a member of the following medical societies: American College of Cardiology and American College of Physicians
Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: sepracor Ownership interest None

Nelson Menezes, MD, RVT, Chief of Vascular Surgery, Assistant Professor, Department of Surgery, Division of Vascular Surgery, The Brooklyn Hospital Center and Cornell University
Nelson Menezes, MD, RVT is a member of the following medical societies: American College of Surgeons, International Society of Endovascular Specialists, Medical Society of the State of New York, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Medical Editor

Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of St Luke's Hospital
Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa
Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Steven J Compton, MD, FACC, FACP, Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals
Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, and American College of Physicians
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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