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Mobile thoracic aortic thrombus is a potential source of arterial embolism. Therapeutic management remains controversial. Systemic anticoagulation and various open surgical procedures are the commonly used therapeutic modalities. We report the successful primary treatment by endovascular stent graft of a mobile thoracic aortic thrombus that had cau...
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... computed tomography (CT) scan revealed an approximately 2-cm 1-cm endoluminal mass in the aortic arch, 1.5-cm distal to the origin of the left subclavian artery (Fig 1). Transthoracic echocardiography confirmed the diagnosis of a mobile, mural aortic thrombus. ...
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... aortic thrombus is a rare pathology that usu- ally originates from an atherosclerotic aortic wall lesion or an aortic aneurysm and is a potential source of visceral, cerebral, and peripheral embolism. The best therapeutic approach remains controversial. Literature reports are mainly of open surgical procedures. Minimally invasive procedures may reduce perioperative morbidity and mortality. We describe a case of mobile thoracic aortic thrombus, causing peripheral embolic occlusion, which was suc- cessfully treated by using endovascular stent-graft (ESG) exclusion as the primary therapeutic approach. A 74-year-old woman with known hypertension, smoking (30 pack-years), and obesity (body mass index, 28) was admitted with a history of recurrent abdominal pain and diarrhea for 3 weeks and acute onset of paresthesia of the right lower leg 1 week later. The abdomen was soft and tender around the umbilicus, without audible bruits. Right popliteal and pedal pulses were absent. A computed tomography (CT) scan revealed an ap- proximately 2-cm ϫ 1-cm endoluminal mass in the aortic arch, 1.5-cm distal to the origin of the left subclavian artery (Fig 1). Transthoracic echocardiography confirmed the diagnosis of a mobile, mural aortic thrombus. No cardiac pathologies were noted. Thrombophilia due to a heterozygous prothrombin mutation was found on screening for coagulation disorders. Serum levels of creatinine (124 umol/L [normal, ...
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Citations
... 7 It is less invasive than open surgical repair, with lower morbidity and mortality, and has been proven effective in recurrence prevention. 3,4,12,13,[20][21][22][23][24][25][26] It corrects the underlying parietal lesion, conditioned by endothelial damage or small atherosclerotic plaque. 21 Technical success as high as 93% has been reported. ...
Background: Embolization to multiple arterial beds associated with primary aortic mural thrombus (PAMT) could result in high morbidity and mortality. There are no recommendations to dictate the best management. This study aims to describe our experience in managing this rare disease.
Methods: A retrospective review of all patients affected by PAMT treated at our institution between January 2015 and December 2021 was performed. Recorded data included demographics, prothrombotic risk factors, imaging findings, clinical presentation, and treatment. Primary outcomes comprised thrombus recurrence, major amputation, and death.
Results: Thirteen patients with PAMT have been included. The median age was 52 years (36–68 years), and the male/female ratio was 1:1.6. The diagnosis of PAMT was made by computed tomography angiography (CTA) in all cases. Prothrombotic conditions were identified in 92% of cases, and most patients (92%) had thoracic PAMT. The most common presentation was acute limb ischemia after thrombus embolization (85%), requiring surgical revascularization. Anticoagulation was promptly started in all patients. Two patients developed heparin-induced thrombocytopenia. Recurrence of embolization/thrombosis was observed in 54% of patients; two underwent endovascular thrombus exclusion with a stent graft. We identified one PAMT-related death and one major amputation with a median follow-up time of 39 months (12–64 months).
Conclusion: Anticoagulation alone as initial therapy could completely resolve PAMT but is associated with high embolization recurrence. Thoracic endovascular aortic repair is feasible and could prevent additional embolization. However, the criteria for its use as a first-line therapy still need to be defined. Our study highlights the importance of closely monitoring these patients.
... Thrombi and neoplasms are known as intra-aortic masses. Treatments for an intraaortic mass include antiplatelet and anticoagulant therapy and surgery [2,7,8]. If only a thrombectomy is performed, the risk for recurrent thrombus formation remains. ...
... If only a thrombectomy is performed, the risk for recurrent thrombus formation remains. Stent graft placement or graft replacement is performed to exclude the abnormal intima to prevent thrombus formation [7]. ...
The aorta may be affected by primary and secondary tumors, as well as by nonneoplastic conditions that present as a periaortic mass. Secondary tumors of the great vessels are rare and malignant in the majority of cases. Because of their rare incidence, deep location, relatively silent initial growth, and both clinical and imaging manifestations that mimic thrombosis, the diagnosis of a secondary tumor of a large vessel can be a difficult challenge. We report a case of aortic metastasis from sarcomatoid carcinoma of the colon. This localization which remains a rare entity and often diagnosed at the metastatic stage. CT scan and transthoracic ultrasound were performed and showed moderate stenosis. The patient was operated. The pathological diagnosis was metastatic carcinosarcoma. We could not detect the origin of malignancy despite additional examinations. These findings emphasize the importance of a precise plan of action for these rare disease.
... 14,[29][30][31][32] It is important to emphasize that endovascular treatment has been increasingly used for thoracic aortic thrombus and appears to be an effective and safe option. 29,[38][39][40][41][42][43] Studies carried out to date do not report differences between use of stent grafts and uncoated stents. 11,14 A meta-analysis of treatment strategies for patients with descending thoracic aortic mural thrombus evaluated 74 patients, 24 of whom were treated with anticoagulation, 19 with open surgery, and 29 with endovascular therapy. ...
A primary aortic mural thrombus (PAMT) is defined as a thrombus attached to the aortic wall in the absence of any atherosclerotic or aneurysmal disease of the aorta or any cardiac source of embolus. It is a rare entity that has high morbidity and mortality. There is no consensus on the ideal treatment of PAMT. The objective of this paper is to review the possibilities for treatment of mobile abdominal aortic mural thrombus. Endovascular therapy and open surgery appear to be the best options for treatment of mobile abdominal aortic mural thrombus. Thus, in patients with favorable anatomy, endovascular therapy is probably the treatment choice, while in those with unfavorable anatomy, open surgery is probably the best option for treatment of a mobile abdominal aortic thrombus. It is important to emphasize that anticoagulation alone can be used as a non-aggressive option and, if this fails, endovascular or surgical methods can then be employed.
... In other words, floating thrombus of the aorta does not occur primarily within a normal aorta most of the time. 1,2 Risk factors such as hypercoagulable states, smoking, steroid use, and oral contraceptive use can make an individual prone to thrombus formation. The most common site of thrombus formation is the descending aorta with a probability of 37.5%. ...
Arterial occlusion may be the cause of chronic pain, and vascular diagnostic procedures should be a part of the workup in patients with unexplained chronic visceral pain.
... Literature review revealed that the only other reported case of isolated PTGM and a major arterial occlusion was a 74-year-old woman with a mobile thrombus of thoracic aorta [2]. Other instances with major arterial occlusion had at least two inherited coagulopathies present concurrently. ...
A prothrombin gene mutation (PTGM) is the second common cause of inherited thrombophilia after factor V Leiden. Hypercoagulable conditions have traditionally been reported to cause venous thrombosis, while arterial thrombosis is a rare occurrence. Studies have reported cases of preexisting hypercoagulable conditions associated with PTGM presenting as thromboembolism; however, none have been recorded with isolated PTGM. A 55-year-old patient was diagnosed to have unilateral popliteal artery thrombosis. He had a past history of provoked deep vein thrombosis. Investigations confirmed PTGM, and no other associated hypercoagulable conditions or peripheral vascular disease were identified. Embolic sources from the heart, aorta, and an atrial septal defect were ruled out. The patient responded to heparin infusion and catheter-directed thrombolysis using TPA. The case is being reported for its uniqueness since this is the first documented case of popliteal artery thrombosis in a patient with isolated PTGM.
... In a report, the authors recommend surgery for patients not responding to ACT (with thrombus resolution) after two weeks of therapeutic anticoagulation (15). Recently, several cases of AMT treated successfully with endovascular treatment have been reported (16,17). Although reports of treatment with stent grafts for AMT have been limited, favorable results may be reported in the future. ...
An aortic mural thrombus (AMT) on a non-atherosclerotic wall is a rare but important cause of arterial thromboembolism. We herein report two cases of AMT in the thoracic aorta. Both showed multiple hypercoagulable factors (case 1: protein S deficiency and positive finding of anti-cardiolipin antibody; case 2: protein C deficiency, gastric cancer, and cisplatin-based chemotherapy) and were successfully treated with anticoagulation. Hypercoagulable states, including malignancy, can influence the formation of AMT; therefore, the accurate assessment of a hypercoagulable condition is necessary when we encounter patients with AMT.
... 7 Yet, asymptomatic mobile aortic thrombus has also been treated both endovascular and surgically due to concerns for potential embolism, again highlighting the lack of treatment consensus. [7][8][9][10] Intervention can also be limited by thrombus location, with the ascending aorta and aortic arch being largely prohibitive to treatment with commercially available stent grafts. Our preference for asymptomatic isolated aortic mural thrombi is conservative medical management with anticoagulation and observation, especially in anatomically challenging areas. ...
Isolated aortic mural thrombus (AMT) is an infrequent occurrence in the setting of an otherwise normal aorta and is a similarly rare occurrence in Takayasu arteritis (TAK). As such, consensus on optimal treatment strategy does not exist, however, invariably necessitates anticoagulation. We report a case of a 21-year-old female who presented with acute chest pain with an isolated descending thoracic AMT on imaging. Diagnosis was elusive after an exhaustive, multidisciplinary evaluation including structural, hypercoagulable, and rheumatologic etiologies. After hypertension control and anticoagulation, she was asymptomatic without embolic sequelae. We proceeded with thoracic aortic resection with interposition reconstruction for the dual function of treatment and definitive diagnosis revealing TAK. This demonstrates a curious presentation of TAK with an equally atypical complication managed with surgery.
... Endovascular aortic surgery has become the treatment of choice in many aortic pathologies including aneurysm, dissection, penetrating atherosclerotic ulcer, traumatic dissection, and intramural hematoma. However few reports have been documented regarding treatment of mobile aortic thrombi with endovascular stent graft [21][22][23][24][25][26]. Despite the fact that the outcome was favourable in all cases, the risk of distal embolization during guidewire manipulation and stent graft repair could be an "obstacle" for endovascular treatment. ...
Free floating thrombus of aortic arch in a minimally atherosclerotic or nonaneurysmal aorta is a rare disease entity which carries a potential risk of distal embolization with catastrophic consequences. We present the case of a 52-years-old patient with ovarian cancer and aortic arch floating thrombus who initially managed with low molecular weight heparin and eventually undergone surgical thrombectomy of left external iliac and common femoral artery due to acute ischemia of left lower leg.
... 25 Endovascular stent grafting provides a minimally invasive therapeutic option, but its role and long-term outcome have not been established yet. 27 Recently, the first successfully treated case of a symptomatic thoracoabdominal mural and floating intra-aortic thrombus was reported, using thoracic endograft, in conjunction with the AngioVac system (Angio-Dynamics, Latham, New York), a device that performs lysis and suction of the thrombus. 28 Although the definition of primary aortic thrombosis implies a macroscopically ''normal'' aorta, we believe that a subclinical, non-identified premature atherosclerotic process may underlie the thrombus formation. ...
A 49-year-old woman was hospitalized for acute left foot arterial ischemia. Arterial Doppler revealed occlusion of the dorsalis pedis and posterior tibial arteries. A computed tomography angiography performed to assess abdominal pain showed hepatic, splenic, renal and pancreatic infarctions. A splenic artery embolism and a small aortic wall thrombus at the celiac trunk were identified. No radiological signs of aortic atherosclerosis were found. No predisposing conditions for secondary aortic thrombosis or intracardiac embolic sources were detected. It was determined that primary aortic thrombosis, a rare though potentially serious condition, was to blame. Isolated aortic mural thrombosis therapy is not well established, although systemic anticoagulation, thrombolysis, thromboaspiration, endovascular stent grafting and surgical thrombectomy have been attempted with varying success. In our patient, systemic anticoagulation therapy was initiated and resulted in aortic thrombus resolution. Close clinical follow-up is crucial, as the aortic thrombus can recur despite anticoagulation and aggressive control of the atherosclerotic risk factors.
... However, the poor general condition of patients, especially those with associated cancer, may be less suited for standard surgery, and IR treatment will prove to be a preferred mode of management. Recently, several manuscripts have described the efficiency of stent-graft exclusion of the thrombus [138][139][140][141][142]. ...
... Filter systems (e.g., temporary caval filters) are not appropriate for the aorta. Therefore, it is recommended that visceral and peripheral angiography should be routinely used at the end of the procedure, to identify potential embolic events caused by the intervention, so they can be treated simultaneously [140]. ...
Vascular emergencies of the retroperitoneum can arise from traumatic or nontraumatic arterial or venous injuries. Advances in interventional radiology technique have permitted less invasive alternative treatments to surgery for the management of aortic and inferior vena cava acute injuries. In this chapter, the MDCT findings of large-vessel vascular emergencies within the retroperitoneum are discussed, with correlative interventional findings and treatment. © Springer International Publishing AG, part of Springer Nature 2018.
