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Concomitant pulmonary embolism and upper limb ischaemia as a first presentation of a patent foramen ovale
  1. Tessa Houtzager1,
  2. Ingvar Berg1,
  3. Thijs Urlings2 and
  4. Robert Grauss3
  1. 1Emergency Medicine, Haaglanden Medical Center, location Westeinde, Den Haag, The Netherlands
  2. 2Radiology, Haaglanden Medical Center, location Westeinde, Den Haag, The Netherlands
  3. 3Cardiology, Haaglanden Medical Center, location Westeinde, Den Haag, The Netherlands
  1. Correspondence to Tessa Houtzager; t.houtzager{at}


A 78-year-old female patient presented to the emergency department with syncope and dyspnoea. The left arm appeared to be cold and radial pulse was not palpable. A CT scan of the chest and left arm with intravenous contrast displayed bilateral central pulmonary embolisms in combination with a left subclavian artery embolism and an atrial septal aneurysm. Transthoracic echocardiography identified a patent foramen ovale with right-to-left shunting confirming the diagnosis of paradoxical embolism. The patient was treated with anticoagulants. In a patient presenting with a combination of a pulmonary embolism and a peripheral arterial embolism, the clinician should consider a right-to-left shunt with paradoxical embolism. In line with this, when diagnosing a peripheral arterial embolism, a central venous origin should be considered. Furthermore, when diagnosing a pulmonary embolism or other forms of venous thromboembolism, the clinician should be aware of signs of a peripheral arterial embolism.

  • cardiovascular medicine
  • venous thromboembolism
  • emergency medicine
  • primary care
  • radiology

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  • Contributors All authors made substantial contributions to the conception of the article and approved the final version to be published. The article was written by TH and revised by IB, RG and TU for important intellectual content. In the emergency department, IB, RG and TU were involved in the initial care of the patient.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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