Free-floating Thrombus Research Articles

Endovascular solutions for symptomatic free-floating thrombus in thoracic aorta in rheumatoid arthritis patients: Two clinical cases

Endovascular solutions for symptomatic free-floating thrombus in thoracic aorta in rheumatoid arthritis patients: Two clinical cases

Surgical thrombectomy for a huge free-floating thrombus in the internal carotid artery without atherosclerotic change

Surgical thrombectomy for a huge free-floating thrombus in the internal carotid artery without atherosclerotic change

Derivation of a clinical prediction score for the diagnosis of clinically significant symptomatic carotid artery disease.

Emergent vascular imaging identifies a subset of patients requiring immediate specialized care (i.e. carotid stenosis > 50%, dissection or free-floating thrombus). However, most TIA patients do not have these findings, so it is inefficient to image all TIA patients in crowded emergency departments (ED). Our objectives were to derive and internally validate a clinical prediction score for clinically significant carotid arterydisease in TIA patients. This was a planned secondary analysis of a prospective cohort study from 14 Canadian EDs. Among 11555 consecutive adult ED patients with TIA/minor stroke symptoms over 12 years, 9882 had vascular imaging and were included in the analysis. Our main outcome was clinically significant carotid artery disease, defined as extracranial internal carotid stenosis ≥ 50%, dissection, or thrombus in the internal carotid artery, with contralateral symptoms. Of 9882 patients, 888 (9.0%) had clinically significant carotid artery disease. Logistic regression was used to derive a 13-variable reduced model. We simplified the model into a score (Symcard [Symptomatic carotid artery disease] Score), with suggested cut-points for high, medium, and low-risk stratification. A substantial portion (38%) of patients were classified as low-risk, 33.8% as medium risk, and 28.2% as high risk. At the low-risk cut-point, sensitivity was 92.9%, specificity 41.1%, and diagnostic yield 1.7%. This simple score can predict carotid artery disease in TIA patients using readily available information. It identifies low-risk patients who can defer vascular imaging to an outpatient or specialty clinic setting. Medium-risk patients may undergo imaging immediately or with slight delay, depending on local resources. High-risk patients should undergo urgent vascular imaging.

Optical Coherence Tomography-Guided Stenting for Common Carotid Free-Floating Thrombus.

Digital subtraction angiography (DSA) has traditionally been considered an effective method for visualizing carotid free-floating thrombus (CFFT), but it falls short in providing detailed structures of the lumen and the composition of thrombi, making it challenging to determine the etiology. Intravascular optical coherence tomography (OCT) is a valuable adjunct to DSA that can precisely evaluate the characteristics of the intrinsic vessel wall and accurately distinguish between red and white thrombus, providing clues to the etiology of CFFTs. Moreover, OCT not only precisely determined the scope of a floating thrombus but also provided guidance for decision-making in endovascular treatment.

The Efficacy of Medical Interventions for Free-Floating Thrombus in Cerebrovascular Events: A Systematic Review.

Although free-floating thrombus (FFT) poses a significant risk of stroke or transient ischemic attack (TIA), optimal management strategies are uncertain. To determine the state-of-the-art of medical interventions for FFT, we conducted a systematic review of the efficacy of various medical interventions and factors influencing FFT resolution and recurrence. A comprehensive search of Embase, PubMed, and ScienceDirect identified 61 studies encompassing 179 patients with FFT-related stroke or TIA treated with anticoagulants, antiplatelets, or their combinations. Primary outcomes assessed were stroke recurrence and thrombus resolution. Statistical analyses (Fisher's exact test, chi-square test, Mann-Whitney test, and Kruskal-Wallis test) utilized significance set at p < 0.05. Over a median follow-up of 7 months, thrombus resolution occurred in 65% of patients, while 11.2% experienced recurrence, primarily as TIAs. Cardioembolism was significantly less common in resolved cases (p = 0.025). Combination therapy (antiplatelets, anticoagulants, and statins) significantly enhanced clot resolution (OR 11.4; 95% CI 1.436-91.91; p = 0.021) compared to monotherapies. Ulcerated plaque was a significant predictor of recurrence (OR 8.2; 95% CI 1.02-66.07; p = 0.048). These findings underscore the superiority of combination therapy in FFT management and highlight the need for targeted interventions in patients with ulcerated plaques to mitigate recurrence risk.

Contrast-enhanced ultrasound reveals free-floating thrombus in carotid artery: The cause of stroke is surprisingly plaque rupture.

Acute stroke poses a serious threat to people's health. The occurrence of a thrombus following the rupture of vulnerable plaques in the carotid artery is a significant contributor to the development of stroke. In previous case reports, it has been challenging to visualize tiny ulcerations within carotid artery plaques using computed tomography angiography (CTA) and digital subtraction angiography (DSA), even when the rupture of the plaque leads to the formation of a free-floating thrombus (FFT). However, in this particular case, contrast-enhanced ultrasound (CEUS) was able to overcome this limitation and provide a more precise assessment, confirming that the FFT formation was indeed a result of plaque rupture rather than any other potential causes. Cases that utilize CEUS to visualize the formation of ulcers and FFT resulting from plaque rupture are even more rare. As such, we present this case to shed light on this infrequent phenomenon. In this case study, we present a 65-year-old male patient who was admitted to the hospital due to headache and abnormal mental behavior for one day. During the routine cervical artery ultrasound examination upon admission, we detected the presence of plaque in the right internal carotid artery of the patient, resulting in luminal stenosis. Additionally, we observed suspected hypoechoic material at the distal end of the plaque. After undergoing CEUS examination, it was definitively determined that an ulcer had formed and a FFT had developed due to the rupture of carotid artery plaque. Subsequent CTA and DSA examinations further confirmed the presence of the FFT. The magnetic resonance imaging (MRI) reveals an acute lacunar infarction in the head of the right caput nuclei caudate, which strengthens the potential link between the patient's neurological and psychiatric symptoms observed during admission. The patient received prompt antiplatelet therapy and underwent cervical artery stenting surgery with the assistance of a distal embolic protection device. Following the procedure, the patient was discharged on the fourth day and experienced a complete recovery. CEUS is a valuable tool for visualizing FFT resulting from the rupture of vulnerable plaques in the carotid artery.

A Free-Floating Aortic Thrombus: An Uncommon Approach to Handle a Rare Clinical Entity.

Thrombotic material in the non-aneurysmatic and non-atherosclerotic aorta is a rare entity without any recommended standard treatment so far. We present a successful treatment strategy for patients who do not fit into any of the common approaches. A free-floating thrombus in the descending aorta was found as source of embolism in an 82-year-old female patient with lower limb ischemia. After initial heparinization of the patient without relevant reduction of the thrombotic mass, the thrombus was removed using an interdisciplinary approach. Under echocardiographic guidance to locate the thrombus, the AngioVac device, usually licensed to remove floating thrombi from the venous system, was used off-label to remove the thrombus by a transfemoral approach. To avoid rebuilding of a new thrombus, the attachment point with an exulcerated plaque in the descending aorta was covered by a stent graft via the same femoral access. The patient did not experience any further embolic events, and the postoperative course was uncomplicated. Patients with uncommon aortic diseases, such as the reported free-floating thrombus, should be treated by an individualized, interdisciplinary approach. Besides the recommended treatment options, there are other uncommon approaches that might offer an alternative in complex cases. Evidence is rare for the treatment of a free-floating thrombus in the descending aorta and the treatment strategy remains discussed controversially. We present a rather uncommon approach of successful off-label treatment for patients who do not fit into any of the common approaches (operative, endovascular, or conservative treatment based on patient's comorbidities). The AngioVac System has already been successfully used off-label in the arterial system but not in the above presented way of treating a free-floating thrombus in a patient with high embolization risk and treatment-limiting comorbidities.

Massive free-floating left atrial thrombus

Massive free-floating left atrial thrombus

Anticoagulants versus Antiplatelet Treatment in the Medical Management of Carotid Floating Thrombus

Carotid free-floating thrombus (CFT) is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by flow on vascular imaging. Unfortunately, there is no clear consensus among experts on the ideal treatment for this pathology. Retrospective analysis of acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients diagnosed with CFT on computed tomography angiogram (CTA) between January 2015-March 2023. We aimed to compare two treatment regimens: anticoagulation (ACT) and antiplatelet (APT) in the treatment of CFT. APT regimens included the use of dual or single antiplatelets (DAPT or SAPT; aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin +/- ASA. Patients that underwent mechanical thrombectomy were excluded. During study time there were 8252 acute ischemic stroke hospitalizations, of which 135 (1.63 %) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.41years ± 12.82;p < 0.01). Other demographic variables were similar between ACT and APT groups. Complete CFT resolution on repeat vascular imaging was numerically higher at 30 days (58.8 vs 31.6 %, respectively; p = 0.1) and at latest follow-up (70.8 vs 50 %; p = 0.1) on ACT vs APT, respectively without reaching statistical significance. Similarly, there was numerically higher rates of any ICH with ACT compared to APT but it did not achieve statistical significance (27.6 % vs 13.5 %; p = 0.5). There were similar rates of PH1/2 hemorrhagic transformation, independence at discharge and similar hospital length of stay between ACT and APT groups. Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5 vs 55.2 %; p < 0.001). The rate of 30-day recurrent stroke was comparable among ACT and APT at 30 days (3.4 vs 0 %; p = 0.1, respectively). Subgroup analysis comparing exclusive ACT vs Dual APT lead to similar results. Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed medically with ACT vs APT. Larger prospective studies are needed.

Comparative Efficacy of Procedural vs. Medical Interventions in the Management of Free-floating Thrombus: A Systematic Review and Meta-analysis (P7-5.002)

Comparative Efficacy of Procedural vs. Medical Interventions in the Management of Free-floating Thrombus: A Systematic Review and Meta-analysis (P7-5.002)

Free-Floating Left Atrial Ball Thrombus Following Transcatheter Edge-to-Edge Mitral Valve Repair With the MitraClip Device

Free-Floating Left Atrial Ball Thrombus Following Transcatheter Edge-to-Edge Mitral Valve Repair With the MitraClip Device

Percutaneous Removal of an Old Calcified Free-Floating Harmful Thrombus in a Patient with Severe Pulmonary Embolism and at Risk for Surgical Treatment

We present a case of a 53-year-old male patient with recurrent pulmonary embolism due to a free-floating right atrial thrombus formation. While thrombolysis was contraindicated due to previous intracranial hemorrhage, and the patient was at high risk for surgical thrombectomy, interventional removal using a percutaneous thrombus aspiration system (AngioVasc) was considered. Despite it’s calcified, free- floating and vulnerable nature, the thrombus aspiration could be carried out safely and the patient feels well. This case highlights the complexities associated with managing high-risk patients with recurrent embolism and the importance of considering modern interventional approaches in cardiac thrombus removal discussions.

Oral Rivaroxaban Versus Warfarin After inferior Vena cava Filter Implantation: A Retrospective Cohort Study.

To assess the efficacy and safety of rivaroxaban compared to warfarin after inferior vena cava (IVC) filter implantation. This retrospective analysis includes data from 100 patients with deep vein thrombosis (DVT) who underwent IVC filter implantation due to a free-floating thrombus (n = 64), thrombus propagation (n = 8), or acute bleeding (n = 8) on therapeutic anticoagulation, catheter-directed thrombolysis (n = 8), or had previously implanted filter with DVT recurrence. Patients were treated with warfarin (n = 41) or rivaroxaban (n = 59) for 3-12 months. Symptomatic venous thromboembolism (VTE) recurrence and bleeding events were assessed at 12 months follow-up. Three (7.3%) cases of VTE recurrence without IVC filter occlusion occurred on warfarin and none on rivaroxaban. The only (2.4%) major bleeding occurred on warfarin. Three (5.1%) clinically relevant non-major bleedings were detected on rivaroxaban. No significant differences existed between groups when full and propensity scores matched datasets were compared. Rivaroxaban seems not less effective and safe than warfarin after IVC filter implantation.

Symptomatic carotid artery intraluminal thrombus: risk of medical management failure and distal embolization

BackgroundCarotid artery intraluminal thrombus (ILT), or free-floating thrombus, is an uncommon cerebrovascular entity with considerable equipoise regarding its clinical management. Likewise, in patients treated with medical management (MM), distal embolization...

Symptomatic Carotid Free-Floating Thrombus: About Management of 50 Cases in a Referral Neurovascular Center

Background: Carotid free-floating thrombus (CFFT) is an uncommon disorder. The aim of this study was to describe a French cohort of CFFT patients. Methods: We conducted a retrospective monocentric study from a Stroke Center among patients admitted for stroke with CFFT. Results: Between January 2017 to December 2019, 2038 ischemic strokes were recorded. A total of 50 patients with CFFT were consecutively included (32 men/18 women). The mean age was 58.2 years (±11.7). Their etiologies were atheroma (46%), carotid dissection and web (20%), hypercoagulability disorders (16%) and arrhythmia (10%). Exclusive medical management was performed in 38 patients (76%): 29 (59.2%) were anticoagulated and 9 (18.4%) received antiplatelets alone in the first week. Surgical intervention was performed in the first 30 days for 11 patients (22%). The main surgical indication was a residual carotid stenosis over 70%. Only three patients had a recurrent stroke in the medical group with anticoagulants. No patients in the antiplatelet group or the surgical group had a recurrent stroke. Conclusions: Our study summarized a large cohort of 50 patients with CFFT. This diagnosis implies the need to search for a local arterial disease and to screen for hypercoagulability states. An initial medical strategy followed by a delayed carotid surgery if the follow-up imaging shows a residual stenosis appears to be safe.

Carotid free-floating thrombus revealed by optical coherence tomography

Carotid free-floating thrombus revealed by optical coherence tomography

Carotid free-floating thrombus stemming from carotid web: co-occurrence of two rare causes of ischemic stroke

BackgroundCarotid web (CaW) and carotid free-floating thrombus (CFFT) are rare yet critical causes of ischemic stroke in young adults.Case presentationA 54-year-old woman presented with a fluctuating right sensory-motor faciobrachial syndrome. A brain MRI scan revealed multiple small recent asynchronous cortico-subcortical ischemic foci in the vascular territory of the left internal carotid artery. A CT angiography identified a CFFT in the left internal carotid artery arising from an underlying CaW. The patient was treated with excellent clinical outcomes with carotid artery stenting and dual antiplatelet therapy.ConclusionsWe provide a structured pathophysiological rationale connecting CaW and CFFT and highlight pivotal therapeutic implications. Further studies are needed to investigate this relationship and guide assessment and treatment.

Endovascular Thrombectomy for a Progressive Stroke Patient With a High-Burden Carotid Free-Floating Thrombus.

Carotid free-floating thrombus (FFT) is a rare cause of acute ischemic events. The optimal management of carotid FFT remains unclear. The optimal and individualized management of carotid FFT should be determined based on the underlying etiology, clinical manifestation, and imaging characteristics. we reported a case with endovascular thrombectomy for a progressive stroke patient with a high-burden carotid free-floating thrombus. ANN NEUROL 2024;95:362-364.

Early inadequate venous flow volume after technically successful balloon angioplasty of radiocephalic arteriovenous fistula: causes and follow-up results.

The objective of this study was to investigate the causes of inadequate venous flow volume, which may lead to re-dysfunction in the early period after technically successful percutaneous transluminal angioplasty (PTA), and the results after one-week follow-up with or without medical treatment. This prospective case-control study included dysfunctional radiocephalic arteriovenous fistula (AVF) cases treated with PTA between December 2021-2022. After PTA, a residual stenosis of less than 30% was considered technically successful. Based on venous flow volume measured 1-2 hours after angioplasty, post-procedural doppler ultrasound (DUS) classified patients as cases (≤400 mL/min) or controls (>400 mL/min). Between groups, pre-post and control DUS parameters were compared. The correlation between fistulography lesion measurements and DUS values was investigated. The pre-procedural DUS resistive index (RI) cut-off value was determined to discriminate groups. A total of 42 patients, 21 cases and 21 controls, were included in the study. Before PTA, 67% of cases had total venous thrombosis, and 71% of controls had stenosis. Lesion measurements and residual stenosis were similar between groups (p>0.05). After PTA, 48% of cases had a free-floating thrombus in the vein, and 10% had a peri-vein hematoma. In pre-procedural DUS, flow volume was the only spectral analysis parameter paired between groups (p=0.057). In post-procedural and control DUS, controls had higher peak systolic velocity (PSV), end-diastolic velocity (EDV), and flow volume, whereas cases had a higher RI (p<0.05). Lesion length and degree of stenosis correlated positively with pre-procedural RI in both groups (p<0.05). The pre-procedural RI cut-off of 0.76 discriminated groups with 76% sensitivity, 67% specificity, 70% positive predictive value (PPV), and 74% negative predictive value (NPV). Low venous flow after PTA has been primarily associated with free-floating thrombi. Routine post-procedural DUS detects low venous flow, high RI, and small thrombi, providing evidence to initiate medical treatment that may prevent early AVF re-dysfunction.

Endovascular Removal of a Large Free-Floating Thrombus of the Descending Thoracic Aorta Using the Angiovac System

Endovascular Removal of a Large Free-Floating Thrombus of the Descending Thoracic Aorta Using the Angiovac System