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BMJ Case Rep. 2010; 2010: bcr1020092413.
Published online 2010 October 21. doi:  10.1136/bcr.10.2009.2413
PMCID: PMC3038028
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Paradoxical digital ischaemia


A young lady presented with an 8-day history of cramping pain in her right hand with ischaemic index and middle fingers (figure 1). Examination revealed no palpable pulses in the right upper limb, no aneurysms, thrills or audible heart murmurs. An electrocardiogram was normal. An arterial duplex scan showed turbulent waveforms in the subclavian artery and triphasic waveforms distally.

Figure 1
Digital ischaemia with secondary pulp space abscesses.

Arch angiography showed an aberrant right subclavian artery (figure 2) and small thrombi occluding the digital vessels of the index and middle fingers. She developed progressive lower-limb oedema and a venous duplex confirmed a non-occlusive thrombus in the right iliofemoral veins extending to the inferior vena cava.

Figure 2
Aberrant right subclavian artery.

A trans-thoracic echo showed poor views of the mitral and tricuspid valves and no obvious thrombus. However, a trans-oesophageal echo showed a patent foramen ovale (PFO) with bi-directional shunting, visible without having to perform a valsalva manoeuvre (video 1).

Video 1

An external file that holds a picture, illustration, etc.
Object name is bcr.10.2009.2413v1alt.jpg

Video of the trans-oesophageal echo showing the patent foramen ovale.

The digital ischaemia was ascribed to a paradoxical embolus via a PFO.

Paradoxical embolism is a rare cause of acute limb ischaemia.1 Probe patient PFO occurs in approximately 30% of the population, but larger defects able to admit the tip of a pencil occur in 7%.2

Trans-esophageal echo has a higher sensitivity (79%), specificity (75%) and positive predictive value (65%) than trans-thoracic echo (7%, 100% and 50%, respectively) in detecting a PFO.3

This highlights not only the need for a diagnosis in patients with acute ischaemia and no obvious source of emboli, but also the importance of trans-oesophageal echo in detecting PFO.


Competing interests None.

Patient consent Obtained.


1. Meister SG, Grossman W, Dexter L, et al. Paradoxical embolism. Diagnosis during life. Am J Med 1972;53:292–8 [PubMed]
2. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20 [PubMed]
3. Belkin RN, Pollack BD, Ruggiero ML, et al. Comparison of transesophageal and transthoracic echocardiography with contrast and color flow Doppler in the detection of patent foramen ovale. Am Heart J 1994;128:520–5 [PubMed]

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