INTROCUTION
Trans-catheter Patent Foramen Ovale (PFO) closure is typically done utilizing femoral access and it is increasingly being performed guided by intra-cardiac echocardiography (ICE) rather than trans-esophageal echocardiogram (TEE). The procedure is considerably more challenging when femoral access is not feasible secondary to congenital or acquired causes. Few case reports have reported the use of the internal jugular veins to perform the procedure in special circumstances(1-3). These procedures have all utilized general anesthesia and trans-esophageal echocardiogram to guide the closure device deployment. We hereby report two cases of PFO closure through the internal jugular vein guided by intra-cardiac echocardiography (ICE) through a left basilic vein access and under conscious sedation.
CASE REPORT Our first patient is a 28 year old male with hypercoagulable state secondary to methylenetetrahydrofolate (MTHFR) mutation complicated by multiple deep venous thromboses (DVT) who had stopped taking anti-coagulation for few years. He is admitted to the hospital for acute DVT and multiple bilateral pulmonary emboli (PE). His vital signs showed sinus tachycardia at 110 bpm and a normal blood pressure. Further imaging with CT scan and lower extremity venous Doppler scans revealed bilateral lower extremity DVTs in femoral veins that extends into the inferior vena cava (IVC) with near occlusion of the IVC (Figure 1). An Echocardiogram showed a PFO with predominant right to left shunt and an enlarged right ventricle (RV). The left ventricular ejection fraction was normal and there were no other abnormalities on echocardiogram.
Our second patient is a 24 year-old female with history of history of recurrent DVTs and May-Thurner syndrome with left common iliac vein stenting who has not been taking anti-coagulation. She is admitted with acute multiple bilateral PEs with evidence of RV strain. Further imaging showed extensive thrombosis of her iliac venous system secondary to in-stent thrombosis. An Echocardiogram showed large PFO with bi-directional shunt.
For both cases, given the extensive clot burden in the ilio-femoral and IVC system, PEs and RV strain on echo, the decision was made to perform trans-catheter local thrombolysis using the EKOS catheter system. However, the presence of a large PFO with right to left shunting was concerning for paradoxical embolus, possible stroke or systemic embolus during manipulation of equipement. Thus, after multi-disciplinary team discussions, a PFO closure was planned prior to thrombolysis or any venous procedures for both patients.