Aortic Mural Thrombus Research Articles

Contemporary management of symptomatic primary aortic mural thrombus

Primary aortic mural thrombus (PAMT) is an uncommon condition but an important source of noncardiogenic emboli with a difficult diagnosis and a high rate of complications, including high mortality. We report our experience of thromboembolic disease from PAMT and review its contemporary management. Retrospective analysis of prospectively collected data of all patients who presented with acute occlusion of a limb or visceral vessels between January 2011 and September 2013 was performed. A total of 88 patients presented with acute occlusion of the extremities or visceral arteries. All underwent extensive evaluation for the possible source of the embolism. Of these 88 patients, 19 patients (mean age, 41.2 years; male:female ratio, 1:2.1) were found to have aortic mural thrombus as the source of distal embolism. Thrombus was located in the thoracic aorta in 10 patients, in the perivisceral aorta in three patients, and in the infrarenal aorta in six patients. Thrombus in the thoracic aorta was treated with stent grafts in four patients, bare metal stents in three patients, and anticoagulation alone in two patients. In the suprarenal abdominal aorta, all three patients underwent trapdoor aortic thrombectomy. Infrarenal aortic thrombus was managed by aortobifemoral embolectomy in two patients, aortic stenting in two patients, surgical thrombectomy in one patient, and anticoagulation alone in one patient. Successful treatment, defined as freedom from further embolic events or recurrence of thrombus, was achieved in 14 of 19 patients (76.4%) with a mean follow-up period of 16.2 months (range, 2-28 months). There were four (21%) thrombus-related deaths, all due to primary thromboembolic insults. One patient needed a below-knee amputation because of a recurrent thrombotic episode. Symptomatic PAMT is an uncommon but important source of noncardiogenic embolus. It appears to occur more frequently in young women. Endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with either stent grafts or closed-cell metal stents. When thrombus is located adjacent to visceral vessels, it should be managed with an open trapdoor thromboembolectomy.

Endovascular stent graft repair of thoracic aortic mural thrombus in a patient with polycythemia vera: A word of caution

Thoracic aortic mural thrombus (TAMT) is a rare pathology and potential source of cerebral, visceral, and peripheral emboli. We present a 62-year-old male in a hypercoagulable state due to primary polycythemia vera (PV) developed TAMT and catastrophic thromboembolisms despite aggressive medical and surgical management. The outcomes and adverse events of endovascular exclusion of TAMT in the presence of PV are unknown. We would recommend proceeding with extreme caution when performing endovascular exclusion of TAMT, as PV may be a prohibitive risk.

A case of aortic thrombosis and embolism preceding the progression of early esophageal cancer

Aortic thrombosis is rare, especially in non-atherosclerotic aortae. A 51-year-old woman presented with intermittent claudication in the right lower extremity. She was diagnosed as having peripheral artery disease on ultrasound. A computed tomography scan showed a large, sessile, aortic mural thrombus from the infrarenal abdominal aorta to the right common iliac artery. An arteriogram showed an abrupt occlusion of the right superficial femoral artery with collateral arteries. She had no risk factors for atherosclerosis. Interestingly, this occurred before early esophageal cancer progressed. Heparin was administered intravenously and later changed to warfarin. In the follow-up period, the thrombus disappeared, and her symptoms improved. A careful investigation for malignant disease is needed when aortic thrombus occurs in patients with no atherosclerosis risk factors.<Learning objective: Aortic thrombosis is rare, especially in non-atherosclerotic aortae. A patient who presented with descending aortic thrombosis and peripheral embolism complicating early esophageal carcinoma is presented. Interestingly, this occurred before the cancer progressed. A careful investigation for malignant disease is needed when aortic thrombus occurs in patients with no atherosclerosis risk factors.>

Aortic Mural Thrombus in the Normal or Minimally Atherosclerotic Aorta

Aortic mural thrombus in a nonaneurysmal minimally atherosclerotic or normal aorta is a rare clinical entity and an uncommon cause of peripheral arterial embolization. Both anticoagulation therapy and aortic surgery are commonly used as primary treatment, but there are no consensuses or clinical guidelines to outline the best management strategy for this unusual problem. This systematic review compares the outcomes of these different strategies for the treatment of aortic mural thrombus. An extensive search of the literature was conducted, and all relevant publications were reviewed, with individual patient data pooled in this meta-analysis. The outcome variables included were persistence or recurrence of aortic thrombus, recurrence of peripheral embolization, mortality, and a composite end point of complications consisting of stroke, limb loss, and bowel resection. Chi-square test and logistic regression analysis were used to compare groups and to find any predictors of adverse outcome. Two hundred patients from 98 articles were considered. Of these, 112 patients received anticoagulation and 88 underwent aortic surgery as primary treatment. Smoking was more prevalent in the surgery group, but no other significant differences in demographics, comorbidities, or mode of presentation were seen between groups. The surgery group was more likely to have aortic thrombus located in the arch, but there were no differences in terms of the mobility or size of the thrombus between groups. Aortic thrombus persisted or recurred in 26.4% of the anticoagulation group and in 5.7% of the surgery group (P < 0.001). Recurrence of peripheral arterial embolization was seen in 25.7% of the anticoagulation group and 9.1% of the surgery group (P = 0.003). Mortality rates were similar at 6.2% and 5.7% for the anticoagulation group and the surgery group, respectively (P = 0.879). Complications were noted in 27% of the anticoagulation group and 17% of the surgery group (P = 0.07), and major limb amputation rates were 9% for the anticoagulation group and 2% for the surgery group (P = 0.004). Logistic regression analysis established thrombus location in the ascending aorta (odds ratio [OR]: 12.7; 95% confidence interval [CI]: 2.3-238.8) or arch (OR: 18.3; 95% CI: 2.6-376.7), mild atherosclerosis of the aortic wall (OR: 2.5; 95% CI: 1-6.4), and stroke presentation (OR: 11.8; 95% CI: 3.3-49.5) as important predictors of recurrence. The results of our meta-analysis seem to favor the surgical management of aortic mural thrombus in the normal or minimally diseased aorta. Anticoagulation as primary therapy is associated with a higher likelihood of recurrence, a trend toward a higher incidence of complications, and a higher incidence of limb loss. Aortic surgery should be considered as primary treatment, particularly for those patients at high risk for recurrence considered to be good operative candidates.

In situ aortic thrombosis secondary to intra-abdominal abscess

SummaryBackground:Abdominal aortic mural thrombus is uncommon in the absence of aneurysm or atherosclerosis.Case Report:We report the case of a 46-year-old man who presented to our institution with perforated appendicitis for which he initially declined surgery. Four days after admission he ultimately consented to appendectomy and abdominal washout. Follow-up imaging to evaluate for intra-abdominal abscess revealed mural thrombus of the infra-renal abdominal aorta extending into the left iliac artery. This thrombus was not present on the admission CT scan. The patient had no clinical signs of limb ischemia. Conservative treatment with therapeutic anticoagulation resulted in resolution of the thrombus.Conclusions:While portal, mesenteric, and major retroperitoneal venous thrombosis are well associated with major intra-abdominal infection and inflammatory bowel disease, aorto-iliac arterial thrombus formation in the absence of associated aneurysm, atherosclerosis or embolic source is exceedingly rare. We are unaware of other reports of in-situ aorto-iliac arterial thrombus formation secondary to perforated appendicitis.

Leriche's Syndrome and Thoracic Aortic Mural Thrombus

Mujer de 63 anos, que consulto por dolor en region proximal de ambas extremidades inferiores que aparecia con la deambulacion y desaparecia con el reposo estando de pie, como antecedentes presentaba obesidad, hipertension y dislipemia. Al examen fisico, los pulsos pedios y tibiales posteriores estaban ausentes, los pulsos popliteos y femoral izquierdo estaban disminuidos y el femoral derecho no se apreciaba. Se realizo una angiografia por tomografia computarizada, que evidencio enfermedad aterosclerotica difusa que afectaba a la aorta abdominal infrarrenal produciendo una oclusion de la aorta terminal y ambas arterias iliacas con recanalizacion en ambas bifurcaciones iliacas, aunque las iliacas externas y las arterias femorales comunes permanecian permeables (figs. 1A y B), y un trombo movil originado en el cayado de la aorta que se extendia distalmente 10 cm hacia la aorta descendente ocluyendo en un 65% su luz (figs. 2A y B). Las pruebas de laboratorio, entre ellas pruebas de trombofilia y enfermedades autoinmunitarias, fueron normales. La paciente rechazo la cirugia e inicio acenocumarol. Figura 2. Figura 1.

Hormone Replacement Therapy–Induced Giant Aortic Thrombus

A 54-year-old white woman presented with a 4-day history of postprandial, periumbilical abdominal pain. She was hypertensive and a 20 pack-year smoker. Her medications included nebivolol and combined estrogen/progesterone hormone replacement therapy (HRT) for hot flashes and mood swings for 8 years. On examination, bowel sounds were normal, and her abdomen was diffusely tender without guarding or rigidity. A contrast-enhanced computerized tomographic scan of the chest and abdomen revealed an extensive intraluminal filling defect in the aorta consistent with a nonobstructive aortic mural thrombus (Figure 1A).

Thrombolysis to Treat Thrombi of the Aortic Arch

Thoracic mobile aortic mural thrombus (TAMT) of the aortic arch is a rare condition. We report 3 cases of symptomatic TAMT treated with systemic alteplase (tissue plasminogen activator [t-PA]) thrombolysis. The first patient was symptomatic with repetitive thromboembolism to the left brachial artery. She was treated with repetitive thrombolysis after surgical embolectomy of the brachial artery. The second patient was symptomatic with splenic infarction and mesenteric ischemia. She was treated with a single cycle of systemic thrombolysis followed by ileocoecal resection. The third patient presented with a TAMT obstructing the left common carotid artery, causing ischemic stroke. After systemic thrombolysis, a reduction in thrombus size was documented; however, the patient died later, of acute heart failure, during the clinical course. On follow-up 6 months after the incidences, the 2 surviving patients were in good condition and free of thromboembolic events. We show that systemic thrombolytic therapy can be performed successfully in patients with TAMT.

Incidental discovery of an ascending aortic thrombus: Should this patient undergo surgical intervention?

Aortic mural thrombus has been recognized in 9% of patients presenting with arterial thromboembolism.1 With the use of computed tomographic (CT) analysis, magnetic resonance imaging (MRI), and transesophageal echocardiography (TEE), its recognition is increasing. Although most reported cases are diagnosed after an embolic event, incidental aortic thrombi will increasingly confront cardiovascular specialists. We present a rare case of an incidental aortic mural thrombus and discuss its management.

Embolies systémiques récidivantes : chercher le thrombus dans… l’aorte

Thoracic aortic mural thrombus is a rare entity and potential source of serious systemic emboli. The progress of computed tomography (CT) angiography and the current use of transesophageal echocardiography (TEE) after any embolic event have considerably increased the frequency of diagnostic and there is a growing interest about the etiopathogenesis, which is still widely misunderstood. Therapeutic management remains controversial. We present a case of floating thrombus in the thoracic aorta detected by contrast-enhanced CT scan. This thrombus was responsible for two close major embolic events and was therefore managed surgically. Finally, outcome was favorable.

Large Free-Floating Intra-Aortic Thrombus

A 56-year-old woman was admitted with chronic chest and back pain with recent exacerbation. Cardiac enzyme levels and ECG were normal. Her history was positive for a patent ductus arteriosus ligation at 13 years of age and a total left mastectomy owing to cancer 4 months earlier. Her son died at 30 years of age as a result of type A aortic dissection. A chest computed …

An unusual cause of chest pain

An unusual cause of chest pain

Anticoagulation is an effective treatment for aortic mural thrombi

Aortic mural thrombi (AMT) in the absence of aortic disease are rare. The appropriate indications and the efficacy of surgical thrombectomy, thrombolysis, and systemic anticoagulation remain controversial. This study, set in an academic medical center, was a retrospective review of five patients with AMT in the absence of aortic disease who underwent treatment between 1997 and 2001. The main outcome measures were morbidity, mortality, and treatment outcome. Three patients were women, and ages ranged from 40 to 77 years. On admission, all patients had symptoms related to thrombus embolization (extremity pain or abdominal pain). Two patients had a history of venous thromboembolism (pulmonary embolism or deep venous thrombosis). Four patients had biochemical evidence of hypercoaguability, and the fifth had malignant disease. Coagulation disorders included increased homocysteine (n = 2) and factor VIII (n = 1), antithrombin III (n = 1) and protein C deficiency (n = 1), and familial dysfibrinogenemia (n = 1). AMT were located in the infrarenal (n = 1), suprarenal (n = 3), and descending thoracic (n = 1) aorta. One patient needed exploratory laparotomy and one needed lower extremity vascular procedures for visceral and limb-threatening ischemia, respectively. Treatment with systemic anticoagulation therapy resulted in complete resolution on follow-up computed tomographic scan or angiogram of the AMT at a median of 60 days. Most patients in whom AMT develops in the absence of underlying aortic disease have underlying coagulation disorders. Anticoagulation therapy alone allows resolution of AMT, with surgical intervention reserved for management of end organ ischemia from thrombus embolization.

Aortic Mural Thrombus Embolization: An Unusual Presentation of Essential Thrombocytosis

Hypercoagulable conditions are increasingly recognized as a causative factor in patients with thromboembolic phenomenon. Essential thrombocytosis (ET) is one such condition. This particular myeloproliferative disorder is most commonly associated with thrombotic complications of the microvasculature and bleeding complications involving mucosal surfaces (e.g., gastrointestinal tract bleeding). This case identifies an uncommon manifestation of ET-aortic mural thrombus leading to visceral embolism. Vascular surgeons should be aware of the diagnosis, treatment, and complications of ET, as patients with this condition may first present with an arterial occlusion.

MAJOR ARTERIAL OCCLUSION BY EMBOLISATION OF AN OCCULT THROMBUS FOLLOWING THROMBOLYTIC THERAPY FOR MYOCARDIAL INFARCTION

SUMMARYWe describe a case in which thrombolytic therapy for acute myocardial infarction resulted in a major arterial embolism from an existing aortic mural thrombus. Clinicians should be alert to this rare complication of thrombolytics, because timely diagnosis and treatment may prevent serious morbidity and mortality.

Idiopathic pedunculated mural thrombus of the nonaneurysmal infrarenal aorta presenting with popliteal embolization: Two cases treated with thrombolytic therapy

The source of emboli to large or medium sized arteries is most commonly the heart; occasionally, it is an aortic aneurysm. The unusual embolic source of aortic mural thrombus in an otherwise minimally diseased aorta has been infrequently reported, and the etiology and management of this entity are not well defined. We describe two cases of infrarenal aortic mural thrombus treated with thrombolytic therapy and review the published experience with this entity. (J Vasc Surg 2000;32:383-7.)

The hyperattenuating crescent sign.

The crescent-shaped area of hyperattenuation within the aortic wall or mural thrombus of an abdominal aortic aneurysm (AAA) is known as the hyperattenuating crescent sign and suggests acute or impending AAA rupture (1). The curvilinear area paralleling the aortic wall is best demonstrated on nonenhanced computed tomographic (CT) images and is of higher attenuation than the intraluminal aortic blood (Figure) (2). At contrast material–enhanced CT, the hyperattenuating crescent is of higher attenuation compared with the adjacent psoas muscle (1).

Primary Aortic Mural Thrombus: Presentation and Treatment

The clinical presentation of patients with acute lower-limb ischemia and primary aortic thrombus prompted this review. Following recognition of the first case in early 1994, relevant patients (n = 6) were kept in a database and were reviewed for presentation, treatment, and follow-up. The median age was 41 and five patients were male. Angiography, computed tomography, and/or magnetic resonance angiography demonstrated one or more aortic sessile or pedunculated thrombus(i) without associated atherosclerotic disease. In two cases, a retropancreatic intraaortic mural thrombus was associated with severe pancreatitis. All other cases presented with acute lower-limb emboli requiring limb salvage embolectomy. Because of significant patient illness, systemic anticoagulation was chosen acutely to prevent recurrent emboli. Interestingly, serial studies demonstrated aortic thrombus resolution. Failure to continue warfarin therapy resulted in recurrent problems (n = 1) unless the instigating event had resolved (n = 3). There were no deaths or amputations. We concluded that surgical embolectomy, when required, with subsequent anticoagulation, results in limb salvage and allows for eventual resolution of the primary aortic thrombus. Long-term anticoagulation is required unless the etiologic process resolves. The literature describes patients with atherosclerosis and overlying thrombus but fails to describe the approach to patients with primary thrombus formation.

Diagnosis and Management of Patients with Peripheral Macroemboli from Thoracic Aortic Pathology

Transesophageal echocardiography (TEE) has improved the detection of thoracic aortic pathology and further elucidated its role as a source of peripheral arterial emboli. Since 1993 we have used TEE to evaluate the thoracic aorta in patients with peripheral emboli without identifiable cardiac sources. Five patients suffered a total of eight embolic events originating from thoracic aortic mural thrombus (TAMT). The four females and one male ranged in age from 56 to 82 years. Emboli occurred to the upper extremities in four instances, lower extremities in three instances, and the visceral vessels in a single instance. Thromboembolectomy was performed in each case except for a patient who initially underwent aortobifemoral bypass. He was discovered to have TAMT after a subsequent embolic event. All patients were anticoagulated after TAMT was identified but in one case anticoagulants were discontinued after an intraabdominal hemorrhage. All patients are alive without limb loss while one patient has experienced recurrent embolization despite anticoagulation. TEE is a sensitive and useful diagnostic modality in patients with "cryptogenic" arterial embolization. Whether surgical management or anticoagulation for the primary lesion is optimal therapy remains a question. However, anticoagulation appears effective in this small experience.

Aortic Mural Thrombus Presenting as Pseudovasculitis

Three months after splenic infarct, a 50-year-old woman underwent arteriography for persistent low-grade fever and abdominal complaints. After 5 months of corticosteroid therapy for "polyarteritis nodosa," another arteriogram confirmed embolic disease; transesophageal echocardiography (TEE) showed a pedunculated mobile thrombus in the aortic arch. We suggest this represents "pseudovasculitis" from an aortic thrombus.