Caught in the Fence

BACKGROUND: Clot-in-transit (CIT) and pulmonary embolism (PE) can lead to hemodynamic collapse and death. Thrombolysis or thrombectomy is often required and has been shown to decrease mortality. CASE-SUMMARY: This patient presented with saddle PE with severe respiratory distress and obstructive shock and later found to have a large clot trapped within the patent foramen ovale (PFO). He inadvertently required a transcatheter thrombectomy of a large PE followed by surgical embolectomy of the CIT from the PFO discovered afterward. DISCUSSION: There is no consensus for treatment of CIT; however, this case presents an additional unique challenge with CIT trapped within the PFO. Hemodynamic stability attained following thrombectomy of PE likely contributed to a successful surgical outcome for this patient. TAKE-HOME MESSAGE: CIT trapped within the PFO in combination with large PE and hemodynamic instability can potentially be treated with transcatheter therapy prior to surgical embolectomy to optimize surgical success.