Multiple Thrombosis With Aortic Occlusion After Heparin-Induced Thrombocytopenia Demonstrated by Multislice Computed Tomography

Abstract

HomeCirculationVol. 113, No. 6Multiple Thrombosis With Aortic Occlusion After Heparin-Induced Thrombocytopenia Demonstrated by Multislice Computed Tomography Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBMultiple Thrombosis With Aortic Occlusion After Heparin-Induced Thrombocytopenia Demonstrated by Multislice Computed Tomography Patrick A. Hein, MD, Alexander Lembcke, MD and Patrik Rogalla, MD Patrick A. HeinPatrick A. Hein From the Department of Radiology, Charité—University Medicine Berlin, Medical School of the Free University and Humboldt University, Campus Charité-Mitte, Berlin, Germany. Search for more papers by this author , Alexander LembckeAlexander Lembcke From the Department of Radiology, Charité—University Medicine Berlin, Medical School of the Free University and Humboldt University, Campus Charité-Mitte, Berlin, Germany. Search for more papers by this author and Patrik RogallaPatrik Rogalla From the Department of Radiology, Charité—University Medicine Berlin, Medical School of the Free University and Humboldt University, Campus Charité-Mitte, Berlin, Germany. Search for more papers by this author Originally published14 Feb 2006https://doi.org/10.1161/CIRCULATIONAHA.105.549287Circulation. 2006;113:e80–e83A 41-year-old woman with restrictive cardiomyopathy due to amyloidosis underwent insertion of an automatic implantable cardioverter-defibrillator for treatment of ventricular tachyarrhythmia. Unfractionated heparin was given as an anticoagulation agent.Sixteen days after the procedure, the patient had abdominal and leg pain, development of paresis of the lower extremities, and both urinal and fecal incontinence. A subsequently performed contrast-enhanced multislice CT demonstrated thrombi in both the left and right atrial appendage and at different levels of the thoracic and abdominal aorta extending into both common iliac arteries (Figure 1 and Figure 2). Imaging data showed complete occlusion of the aortic bifur- cation. CT moreover displayed a large collateral vessel emerging from the superior mesenteric artery and good opacification of the peripheral arteries, suggesting a subacute event that did not necessitate urgent surgery (Figure 3). Download figureDownload PowerPointFigure 1. A through F, Series of representative axial images illustrating multiple clots in both the left and right atrial appendage (indicated by arrows in A) and in the thoracic aorta (B). Axial images at a lower level demonstrate clots in the abdominal aorta with complete occlusion of the vessel lumen (C through E).Download figureDownload PowerPointFigure 2. Maximum intensity projection in sagittal orientation demonstrates ventrally located arterial thrombus in the thoracic aorta as well as dorsally located thrombotic material in the abdominal aorta not compromising perfusion of the celiac artery, the superior mesenteric artery, or renal arteries, whereas the infrarenal aorta is completely occluded.Download figureDownload PowerPointFigure 3. Rendered from the original data set, this 3-dimensional image in coronal view depicts complete thrombotic obstruction of the infrarenal aorta and a large collateral vessel emerging from the superior mesenteric artery. The presence of the collateral pointed to a subacute event.Subsequently performed platelet count evaluation revealed thrombocytopenia, and results from heparin-induced platelet activation assay and PF4/polyanion enzyme immunoassay were strongly positive for heparin-induced thrombocytopenia antibodies. Imaging and clinical findings supported the diagnosis of heparin-induced thrombocytopenia, and administration of a recombinant hirudin agent (Lepirudin) was immediately initiated. Specific therapy led to a partial resolution of the clots, which was demonstrated by follow-up imaging (Figure 4). Download figureDownload PowerPointFigure 4. Follow-up scan 4 weeks after initiation of specific therapy revealed partial resolution of the clots in the thoracic and abdominal aorta as well as in the left iliac artery, with persistent obstruction of the right iliac artery. Images in A through C, comparative in anatomic level and in spatial orientation to those shown in Figure 1E, Figure 2, and Figure 3, respectively, demonstrate posttherapeutic reduction of aortic occlusion.FootnotesCorrespondence to Patrick. A. Hein, MD, Department of Radiology, Charité – University Medicine Berlin, Medical School of the Free University and Humboldt University, Campus Charité-Mitte, Schumannstrasse 20/21, 10117 Berlin, Germany. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Bienz M, Obrocki P, Russell J, Jena R and Mendichovszky I (2019) Heparin-induced thrombocytopaenia presenting as acute aortic mural thrombosis, BJR|case reports, 10.1259/bjrcr.20180025, 5:1, (20180025), Online publication date: 1-Feb-2019. February 14, 2006Vol 113, Issue 6 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.105.549287PMID: 16476856 Originally publishedFebruary 14, 2006 PDF download Advertisement SubjectsAnticoagulantsComputerized Tomography (CT)Thrombosis