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.