Abstract
BackgroundIdiopathic free-floating thrombus (FFT) of the aorta is a rare occurrence, but it can lead to catastrophic consequences. The initial symptoms are typically cerebral or peripheral embolisms. Surgical thrombectomy and thrombolysis are two primary treatments for FFT. Here, we report three cases of patients with idiopathic FFT in the absence of coagulopathy who were treated successfully by surgery with no recurrent thrombi or relapse of symptoms.Case presentationCase 1 involved a 72-year-old male patient with a pedunculated thrombus in the distal aortic arch. Case 2 involved a 62-year-old female patient with a cylinder thrombus in the aortic arch and left common carotid artery. Case 3 involved a 65-year-old male patient with three pedunculated thrombi in the ascending aorta, aortic arch, and left subclavian artery. None of the patients had clinical signs of coagulopathy. Pedunculated or cylinder thrombi have a greater risk of breaking off, which can produce severe peripheral embolism in contrast with intramural thrombi (73% vs. 12%). Due to the high embolism risk for each patient, conservative medical treatment by heparinization was deemed inappropriate, so each patient underwent emergency surgical thrombus removal. After surgery, each of the three patients was treated with warfarin for secondary prevention of thromboembolism. At 7-month follow-up in outpatient practice, a computed tomography (CT) scan indicated that Patient 1 had no recurrent thrombus, and the patient has been symptom-free for 11 months. At 1-month follow-up in outpatient practice, a CT scan indicated that Patient 2 had no recurrent thrombus, and the patient has been symptom-free for 8 years. At 3-week follow-up in hospital, a CT scan indicated that Patient 3 had no recurrent thrombus, but he failed to follow-up after discharge, so his follow-up status is unknown.ConclusionsFor a large pedunculated or cylinder thrombus located in the thoracic aorta, surgical thrombectomy should be performed. And, in surgical thrombectomy, the location of the cannulas and cross-clamp should be selected carefully according to the location of the thrombus. After surgery, anticoagulant is important to prevent recurrent idiopathic thrombi.
Highlights
Idiopathic free-floating thrombus (FFT) of the aorta is a rare occurrence, but it can lead to catastrophic consequences
For a large pedunculated or cylinder thrombus located in the thoracic aorta, surgical thrombectomy should be performed
In surgical thrombectomy, the location of the cannulas and cross-clamp should be selected carefully according to the location of the thrombus
Summary
In 10,671 autopsies, Machleder et al reported an incidence of thoracic aortic thrombus at 0.45%, of which 17% had autopsy evidence of distal embolization [2]. For pedunculated thrombi, which carry a high risk of embolism, surgical thrombectomy should be performed. Choukroun et al identified thrombi located in the ascending aorta and aortic arch as an indication that surgery should be performed to prevent stroke [4]. In cases whose risks associated with surgery are comparatively high, thrombolysis has been the primary modality of treatment [5]. There is no knowing optimal prothrombin time-international normalized ratio (PT-INR) In these three cases, PT-INR is controlled at 2.0, and recurrent thrombi are not seen. Surgical thrombectomy should be performed for large pedunculated or cylinder thrombi located in the thoracic aorta. In surgical thrombectomy, the location of the thrombus should determine where to perform the outflow cannulas or cross-clamp and whether DHCA should be induced.
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