Paradoxical embolism is defined as venous thrombosis causing systemic embolization through a
right-to-left shunt.

We, herein, report a case of bilateral total knee arthroplasty and developed paradoxical embolism
caused by patent foramen ovale. A sixty-two year old female had a simultaneous, total knee arthroplasty for
primary osteo-arthritis. A pulmonary emboli was suspected on the thirteenth post operative day. Two days
later, acute arterial insufficiency at her leg was suspected. An embolectomy and intra-operative tranesophageal
echocardiogram was performed. It showed patent foramen ovale (PFO) 2-3 mm. Five days after embolectomy,
she developed infarction lesion at the right occipital area. The foramen ovale was closed with a closure device
nineteen days later. The patient eventually could walk using a walker. She was discharged thirty-six days after
the operation.

Keyword: Paradoxical embolism, Bilateral total knee arthroplasty, Pulmonary embolism, Patent foramen
ovale