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Case presentation: A 62-year-old woman presented to the emergency department with the acute onset of paresthesia and severe left arm pain; an aortogram revealed an occlusion of the proximal left subclavian artery (Figure 1). The patient underwent emergency right-to-left axillary-axillary bypass grafting and was discharged on aspirin 81 mg. She again presented to the hospital 4 weeks later with symptoms of a stroke; magnetic resonance imaging and angiography revealed multiple left-sided acute embolic infarcts and proximal occlusion of the left internal carotid and vertebral artery (Figure 2). The patient underwent emergency endarterectomy during which fresh thrombus was removed; of note, there was no underlying atherosclerotic plaque. Three days after surgery, the patient developed a deep venous thrombosis and subsequent bilateral pulmonary emboli of the left leg. A transesophageal echocardiogram revealed the presence of a patent foramen ovale (PFO), an atrial septal aneurysm, and a large right-to-left shunt (Movie I in the online-only Data Supplement). A hypercoagulable workup was positive for heterozygous factor V Leiden mutation.Figure 1. Aortogram revealing acute occlusion of the proximal left subclavian artery.Figure 2. Magnetic resonance angiography of the brain revealing proximal acute occlusion of the left internal carotid and vertebral artery.### OverviewIschemic stroke occurs annually in ≈700 000 patients in the United States and causes significant morbidity and mortality.1 Cryptogenic stroke occurs in ≈45% of cases.2 Paradoxical embolism through a PFO may …

Recurrent Paradoxical and Pulmonary Embolism, Hypercoagulable State, and Patent Foramen Ovale