From the Guidelines
Surgical thrombectomy is the preferred approach for managing a thrombus in transit through a patent foramen ovale (PFO), as it involves direct removal of the thrombus and closure of the PFO to prevent recurrence. This recommendation is based on the most recent and highest quality evidence available, which emphasizes the importance of urgent intervention in such cases to prevent paradoxical embolism and its potentially devastating consequences, including stroke or other arterial occlusions 1.
The presence of a PFO in patients with a thrombus in transit increases the risk of death, ischemic stroke, peripheral arterial embolism, and a complicated hospital course, as highlighted in earlier studies 1. More recent guidelines suggest that PFO closure is beneficial for carefully selected patients with cryptogenic stroke, particularly those with an atrial septal aneurysm or a substantial shunt size, as demonstrated in trials such as the CLOSE and REDUCE trials 1.
Key considerations in the management of a thrombus in transit through a PFO include:
- Immediate initiation of systemic anticoagulation with intravenous unfractionated heparin if surgery is contraindicated
- Potential use of thrombolysis with tissue plasminogen activator (tPA) in hemodynamically unstable patients who cannot undergo surgery, despite the increased bleeding risk
- Long-term anticoagulation with warfarin or direct oral anticoagulants like rivaroxaban or apixaban for at least 3-6 months after initial stabilization
- The critical need for urgent intervention due to the high risk of paradoxical embolism and the significant mortality rate associated with untreated thrombus in transit through a PFO.
Given the complexity and the high stakes of managing a thrombus in transit through a PFO, a multidisciplinary approach involving cardiology, neurology, and potentially cardiothoracic surgery is essential to ensure the best possible outcomes for patients, as supported by the latest clinical guidelines and research findings 1.
From the Research
Management of Thrombus in Transit through PFO
The management of a thrombus in transit through a patent foramen ovale (PFO) is a complex and high-risk condition that requires prompt and effective treatment. The goals of management are to prevent systemic thromboembolism and reduce the risk of mortality.
- Medical Management: Anticoagulation therapy, such as apixaban, can be used to prevent further thrombus formation and reduce the risk of systemic embolism 2, 3.
- Surgical Management: Surgical thrombectomy and PFO closure can be performed in patients with large thrombi or those who are at high risk of systemic embolism 2, 4.
- Percutaneous Management: Transcatheter PFO closure can be performed in patients who are not candidates for surgical closure or who have a high risk of surgical complications 3, 4.
- Inferior Vena Cava Filter Placement: Placement of an inferior vena cava filter can be used to prevent recurrent episodes of thromboembolism 2, 4.
- Multidisciplinary Approach: Management decisions should be made on a case-by-case basis, taking into account the patient's individual risk factors and clinical presentation, and should involve a multidisciplinary team of healthcare professionals 5.
Treatment Options
The optimal treatment of thrombus in transit through PFO is not established, and multiple treatment options have been described, including:
- Anticoagulation alone
- Systemic thrombolysis
- Surgical embolectomy
- Endovascular catheter-based therapies 5
Importance of Prompt Treatment
Thrombus in transit through PFO can embolize to the pulmonary circulation in a matter of seconds and be immediately fatal, highlighting the importance of prompt and effective treatment 5.