Transthoracic echocardiography (TTE) on the next day was interpreted as successful device closure with small residual shunt. The patient was discharged but after a few days was readmitted for leg pain and numbness, especially in the left leg. Clinical examination was noted as normal, and she was discharged without additional imaging.

At follow-up visit after 1 year, TTE and fluoroscopy showed that the device had embolized, and contrast computer tomography (CT) scan revealed the device positioned in the iliac bifurcation. Catheterization was performed with venous and arterial access. There was evidence of local dissection of the distal aorta extending from the renal arteries to the bifurcation, where an organized thrombus was located with reduced flow into the left common iliac artery, but with good collateral flow (Figs. 22.2a, b and 22.3a, b). The invasive blood pressure difference from the distal aorta to the common iliac artery was 35 mmHg. An attempt was made to retrieve the device with a snare from the right femoral artery, but the device could not be mobilized probably due to endothelialization. The PFO was crossed from the right femoral vein using a 25-mm PTS sizing balloon resized to a stretched diameter of 18 mm (Fig. 22.4a). A 21-mm Occlutech Figulla ASD Occluder (Occlutech International, Helsingborg, Sweden) was implanted without complications (Fig. 22.4b).

In collaboration with the vascular surgery team, initial conservative treatment was recommended with the option for open surgical repair of the distal aorta and proximal iliac arteries in case of symptom progression. During the following 4 years, CT findings have been unchanged, and the patient has reported low degree of claudication and declined open surgery due to the low intensity of symptoms.