Case Report
Endovascular Management of a Mobile Thoracic Aortic Thrombus Following Recurrent Distal Thromboembolism: A Case Report and Literature Review
Vascular and Endovascular Surgery 2014, Vol. 48(3) 246-250 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574413513845 ves.sagepub.com
Daniel J. Scott, MD1, Joseph M. White, MD1, and Zachary M. Arthurs, MD1
Abstract Sources of lower extremity and visceral arterial thromboembolism most commonly include the heart and proximal aneurysmal disease. Infrequently, further workup of ‘‘cryptogenic’’ emboli will reveal a mural atheroma or thrombus of the descending thoracic aorta. Without prospective data, anticoagulation and open surgical thrombectomy with or without aortic replacement have been the standard approach. Presented is a case of a floating mural thrombus in the setting of superior mesenteric and femoral arterial thromboembolism that was effectively treated with endovascular stent graft exclusion. Keywords endovascular, stent graft, mobile thrombus, floating thrombus, atheroma, embolism, thoracic aorta
Introduction Sources of visceral and lower extremity thromboembolism most often include the heart (80%) and proximal aneurysmal disease (5%-10%).1 Oliver was among the first to describe thoracic aortic thrombus as a clinically significant source of distal embolic events.2 Given the rarity of this phenomenon, barely more than 150 encounters have been described in the literature, all of which are isolated to small series or case reports.3-6 Although current expert opinion has reinforced anticoagulation as initial therapy, the indications for and type of operative intervention are less clear. Historically, open surgical intervention was reserved for favorable operative candidates in the setting of concerning morphologic features (ie, mobile thrombi, large thrombi, recurrent embolism, etc) or those that failed to resolve with medical management.3,6,7 Advancement of endovascular techniques and devices provides a minimally invasive alternative to patients otherwise deemed poor surgical candidates. Reported is a case study and review of current literature surrounding the endovascular management of symptomatic thoracic aortic mobile thrombi (TAMT).
Case Report
exclusion of acute coronary syndromes, evaluation included computed tomography (CT), revealing a large ‘‘saddle’’ thrombus in the origin of the superior mesenteric artery (SMA; Figure 1). Following systemic anticoagulation with heparin, she was taken emergently to the operating room. Access was accomplished via the left brachial artery, and a 7F/80 cm sheath was advanced to level of the L1 vertebra. The SMA was cannulated, and mechanical thrombectomy was performed with a catheter-directed rheolytic/thrombolytic system (AngioJet; MEDRAD Inc, Warrendale, Pennsylvania). Following successful thrombolysis, a 7 22 mm2 balloon expandable stent (iCast; Atrium Medical Corp, Hudson, New Hampshire) was placed within the origin of the SMA and flared (Figure 2). The distal vessels were treated with papaverine. Completion angiography demonstrated return of flow to all major branches and she was returned to the intensive care unit (ICU) for observation. Within the next 24 hours, she developed class IIB ischemia of her left lower extremity. Concern for an additional embolic event necessitated urgent operative exploration and confirmed
1
Patient is a 77-year-old African American female who presented with a primary complaint of severe upper abdominal pain of approximately 48 hours duration. Cardiovascular risk factors included coronary artery disease, hypertension, hyperlipidemia, obesity, and remote smoking history. Following
Department of Vascular Surgery, San Antonio Military Medical Center, Ft Sam Houston, TX, USA Corresponding Author: Daniel J. Scott, Department of Vascular Surgery, San Antonio Military Medical Center, 3851 Roger Brooke Dr, Ft Sam Houston, TX 78234, USA. Email: [email protected]
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
Scott et al
247
Figure 1. Contrast-enhanced computed tomography (CT) demonstrating ‘‘saddle’’ thromboembolism of the superior mesenteric artery.
by angiography (Figure 3). Via open femoral cutdown, balloon thrombectomy was performed. Clot was returned from both superficial and deep femoral arteries and was sent for pathology review. Return of backbleeding and distal signals were demonstrated and the patient returned to the ICU. Due to concern for recurrent embolism, source workup included transthoracic echocardiography with no demonstrable abnormality. Inability to clear her aortic root and arch, however, prompted further evaluation with transesophageal echocardiography (TEE). A large atheroma with associated mobile thrombus in the descending thoracic aorta was demonstrated just distal to the right subclavian origin (Figure 4, Video 1). Given the location of the atheroma, mobile features, and recent embolic events, it was deemed amenable to exclusion by stent graft placement. The patient returned to the operating room, her left radial artery was accessed, and a flush/pigtail catheter was advanced into the aortic arch. The right common femoral artery was additionally accessed, dilated, and an 11F sheath maintained. An extra-stiff guidewire was advanced to the aortic root and intravascular ultrasound used. A large mobile thrombus was visualized approximately 50 mm distal to the subclavian artery. To achieve at least 30 mm seal, an 80-mm thoracic stent graft device (Zenith TX2; Cook Medical Inc, Bloomington, Indiana) was
Figure 2. Postoperative computed tomography (CT) following successful catheter-directed thromboembolectomy and superior mesenteric artery stent placement.
deployed just distal to the right subclavian orifice. Completion angiography demonstrated exclusion of the atheromatous thrombus (Figure 5). Three days following stent graft exclusion, she was tolerating a diet, maintaining renal function, and demonstrating no additional embolic events. She was discharged on clopidogrel and maximal statin therapy. At 9-month follow-up, a repeat CT angiography (CTA) was performed, which demonstrated continued patency of her left femoral and SMAs. Her thoracic endograft remains in place with appropriate seal, and no evidence of additional thrombi, dissection, stent fracture, or migration.
Discussion Thoracic aortic mobile thrombi are rare sources of distal mesenteric or lower extremity emboli. Risk factors include young age, smoking, and family history of atherosclerotic disease. Nevertheless, the incidence of this disease process is increasing, likely secondary to expanded use of sensitive noninvasive evaluations including TEE, CTA, and magnetic resonance (MR) angiography in further evaluating previously ‘‘cryptogenic’’ emboli.
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
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Vascular and Endovascular Surgery 48(3)
Figure 3. Left lower extremity angiogram confirming recurrent thromboembolism.
Figure 4. Representative transesophageal echocardiographic image of descending thoracic aortic thrombus.
Several authors have endorsed TEE as a requirement to diagnose TAMT. The real-time evaluation allows for analysis of both morphologic (ie, sessile vs pedunculated) and dynamic (mobile/floating vs fixed) properties of the thrombus, ultimately providing clues on its embolic potential.6-9 In some institutions with the technological capability, MR imaging (MRI)/MR angiography, may also be helpful in this regard, particularly with the additional use of cine-MRI to evaluate the mobility of the thrombus. Since the recognition of this disease process, multiple treatment modalities have been described with varying levels of invasiveness and effectiveness. These approaches include anticoagulation alone,3,6 transfemoral thrombectomy,6 open
Figure 5. Intraoperative (completion) angiogram following successful exclusion with thoracic stent graft.
surgical extirpation,6,7 and aortic replacement.6 In contrast to abdominal aortic sources of embolic thrombi, the use of stent grafts in this manner has only been recently described as a viable option.9,10 Although experiences are currently limited to few case reports (and with resultant reporting bias), the early results have been promising with 100% technical success, no early recurrences, and no wire or device complications (including leak, aberrant placement, migration, or wire complications to include inadvertent embolism; Table 1).9,11-17 Nevertheless, several considerations should be made when approaching these lesions. These include (1) careful management of wires to prevent iatrogenic emboli; (2) use of angiography (via left subclavian) and/ or intravascular ultrasonography to accurately identify and exclude the affected segment of aorta; (3) planning of at least 1 to 2 cm proximal and distal landing zone/overlap; (4) postprocedural evaluation of mesenteric and lower extremity vessels. The etiology of TAMT is relatively enigmatic and often afflicts young patients with nearly normal aortas with absent or limited atheromatous base.5 Multiple factors have been implicated to include hypercoagulable states (including nonaortic malignancy), smoking, steroid use, trauma, drug abuse, heparin-induced thombotic thrombocytopenia, rheumatism, or history of vasculitis.6 Adversaries to an endovascular approach argue lack of tissue diagnosis. While extremely rare, primary aortic malignancy is always a concern, particularly in otherwise young and normalappearing aortas.18,19 Opportunely, most mobile thrombi of the aorta are diagnosed following embolic phenomena of the lower extremity and present an opportunity for histological analysis of representative clot on initial treatment/revascularization. The clot removed from this patient’s initial operation demonstrated
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
249
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
2010 2011 2004 2012
Wolf et al15 Giovanni et al17 Criado et al9 Current patient
1 2 1 1
1 1 1 1 1 63F 45F/67M 60F 78F
63M 70M 74F 47F 56M
Age
CTA/TTE TEE TEE TEE
TEE/CTA TEE CTA/TTE CTA CTA
Diagnostic Modality 2
Gore TAG (26 100 mm2) Bolton Relay (22 100 mm2)/(34 100 mm2) PTFE/Cordis Palmaz stent (30 100 mm2) Cook Zenith TX2 (28 140 mm2)
LeMaitre EndoFit (40 180 mm ) Gore TAG (34 100 mm2) Gore TAG (37 150 mm2) Gore Excluder (26 100 mm2) Gore TAG (28 100 mm2)
Device
NR Warfarin/warfarin Warfarin Clopidogrel
Clopidogrel Warfarin/ASA Warfarin NR Warfarin
Postoperative Antiplatelet/ Anticoagulation
Ulcerated plaque Ulcerated plaque PT mutation NR Hyperhomocysteine, MTHFR mutation, lupus anticoagulant Atheroma NOS Atheroma NOS Ulcerated plaque Atheroma NOS
Etiology
Abbreviations: TEE, transesophageal echocardiogrphy; PTFE, polytetrafluoroethylene; CTA, computed tomography angiography; ASA, acetylsalicylic acid; PT, prothrombin; MTHFR, methylenetetrahydrofolate reductase; NOS, not otherwise specified. a Device manufacturers: LeMaitre Vascular, Inc, Burlington, Massachusetts; Cook Medical Inc, Bloomington, Indiana; Gore Medical, Flagstaff, Arizona; Cordis Corp, Miami Lakes, Florida; Bolton Medical Inc, Sunrise, Florida.
2008 2008 2005 2008 2007
11
Year # Patients
Saratzis et al Zhang et al12 Fueglistaler et al13 Luebke et al16 Piffaretti et al14
Author
Table 1. Current Reported Experience With Endovascular Management of Mobile Thoracic Aortic Thrombi.a
250
Vascular and Endovascular Surgery 48(3)
no evidence of malignancy on pathology review; therefore, exclusion with stent grafting was able to be performed with confidence of no underlying malignancy. Intra-arterial biopsy has been described in the interventional radiology literature, although the potential for embolic complication is often prohibitively high.20 Instead, preoperative MRI is considered the gold standard imaging modality.19,21 If suspicion for primary malignancy exists, excision and graft replacement is favored over confirmative tissue biopsy. Recurrence rates up to 10% to 20% have been reported following open intervention.3,22 This has led to a recommendation of lifelong anticoagulation following open repair.3 One additional advantage of stent graft exclusion is the ability to obviate lifelong anticoagulation and its inherent morbidity. Once a hypercoagulable state is excluded, antiplatelet therapy alone can be initiated without concurrent anticoagulation.
Conclusion Thoracic aortic mobile thrombi are a rare but significant source of distal emboli. Effective detection and characterization by TEE or cine-MRI help qualify the embolic potential of these previously enigmatic lesions. In contrast to open surgical management, endovascular stent graft exclusion has demonstrated promising results with little morbidity. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material The online video 1 is available at http://ves.sagepub.com/supplemental. Video 1. Real-time transesophageal echocardiogram demonstrating mobility of thoracic aortic thrombus.
References 1. Lord JW Jr, Rossi G Daliana M, Drago JR, Schwartz AM. Unsuspected abdominal aortic aneurysms as the cause of peripheral arterial occlusive disease. Ann Surg. 1973;177(6):767-771. 2. Oliver DO. Embolism from mural thrombus in the thoracic aorta. Br Med J. 1967;3(5566):655-656. 3. Choukroun EM, Labrousse LM, Madonna FP, Deville C. Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 cases. Ann Vasc Surg. 2002;16(6):714-722. 4. Goueffic Y, Chaillou P, Pillet JC, Duveau D, Patra P. Surgical treatment of nonaneurysmal aortic arch lesions in patients with systemic embolization. J Vasc Surg. 2002;36(6):1186-1193. 5. Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromboses of the aortic arch without aortic debris. A transesophageal echocardiographic finding associated with unexplained arterial embolism. The Filiale Echocardiographie de la Societe Francaise de Cardiologie. Circulation. 1997;96(1):288-294.
6. Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Ruckert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta—an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-457. 7. Namura O, Sogawa M, Asami F, Okamoto T, Hanzawa K, Hayashi J. Floating thrombus originating from an almost normal thoracic aorta. Gen Thorac Cardiovasc Surg. 2011;59(9):612-615. 8. Reber PU, Patel AG, Stauffer E, Muller MF, Do DD, Kniemeyer HW. Mural aortic thrombi: an important cause of peripheral embolization. J Vasc Surg. 1999;30(6):1084-1089. 9. Criado E, Wall P, Lucas P, Gasparis A, Proffit T, Ricotta J. Transesophageal echo-guided endovascular exclusion of thoracic aortic mobile thrombi. J Vasc Surg. 2004;39(1):238-242. 10. Shames ML, Rubin BG, Sanchez LA, Thompson RW, Sicard GA. Treatment of embolizing arterial lesions with endoluminally placed stent grafts. Ann Vasc Surg. 2002;16(5):608-612. 11. Saratzis N, Melas N, Saratzis A, Lazaridis J, Kiskinis D. Minimally invasive endovascular intervention in emergent and urgent thoracic aortic pathologies: single center experience. Hellenic J Cardiol. 2008;49(5):312-319. 12. Zhang WW, Abou-Zamzam AM, Hashisho M, Killeen JD, Bianchi C, Teruya TH. Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization. J Vasc Surg. 2008;47(1):193-196. 13. Fueglistaler P, Wolff T, Guerke L, Stierli P, Eugster T. Endovascular stent graft for symptomatic mobile thrombus of the thoracic aorta. J Vasc Surg. 2005;42(4):781-783. 14. Piffaretti G, Tozzi M, Caronno R, Castelli P. Endovascular treatment for mobile thrombus of the thoracic aorta. Eur J Cardiothorac Surg. 2007;32(4):664-666. 15. Wolf PS, Burman HE, Starnes BW. Endovascular treatment of massive thoracic aortic thrombus and associated ruptured atheroma. Ann Vasc Surg. 2010;24(3):416 e9-e12. 16. Luebke T, Aleksic M, Brunkwall J. Endovascular therapy of a symptomatic mobile thrombus of the thoracic aorta. Eur J Vasc Endovasc Surg. 2008;36(5):550-552. 17. Giovanni N, Daniela M, Giovanni M, et al. Endovascular treatment of thoracic aortic floating thrombus in patients presenting with acute lower limb ischemia. Int J Vasc Med. 2011;2011: 604362. 18. Khan A, Jilani F, Kaye S, Greenberg BR. Aortic wall sarcoma with tumor emboli and peripheral ischemia: case report with review of literature. Am J Clin Oncol. 1997;20(1):73-77. 19. Chiche L, Mongredien B, Brocheriou I, Kieffer E. Primary tumors of the thoracoabdominal aorta: surgical treatment of 5 patients and review of the literature. Ann Vasc Surg. 2003; 17(4):354-364. 20. Ronaghi AH, Roberts AC, Rosenkrantz H. Intraaortic biopsy of a primary aortic tumor. J Vasc Interv Radiol. 1994;5(5):777-780. 21. Mohsen NA, Haber M, Urrutia VC, Nunes LW. Intimal sarcoma of the aorta. AJR Am J Roentgenol. 2000;175(5):1289-1290. 22. Patra P, Chaillou P, Duveau D. Traitement chirurgical des lesions emboligenes de la crosse de l’aorte. In: Techniques et Strategies en Chirurgie Vasculaire. 3rd ed. Paris, France: Pharmapost;1997: 11-31.
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
Endovascular Management of a Mobile Thoracic Aortic Thrombus Following Recurrent Distal Thromboembolism: A Case Report and Literature Review
Vascular and Endovascular Surgery 2014, Vol. 48(3) 246-250 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574413513845 ves.sagepub.com
Daniel J. Scott, MD1, Joseph M. White, MD1, and Zachary M. Arthurs, MD1
Abstract Sources of lower extremity and visceral arterial thromboembolism most commonly include the heart and proximal aneurysmal disease. Infrequently, further workup of ‘‘cryptogenic’’ emboli will reveal a mural atheroma or thrombus of the descending thoracic aorta. Without prospective data, anticoagulation and open surgical thrombectomy with or without aortic replacement have been the standard approach. Presented is a case of a floating mural thrombus in the setting of superior mesenteric and femoral arterial thromboembolism that was effectively treated with endovascular stent graft exclusion. Keywords endovascular, stent graft, mobile thrombus, floating thrombus, atheroma, embolism, thoracic aorta
Introduction Sources of visceral and lower extremity thromboembolism most often include the heart (80%) and proximal aneurysmal disease (5%-10%).1 Oliver was among the first to describe thoracic aortic thrombus as a clinically significant source of distal embolic events.2 Given the rarity of this phenomenon, barely more than 150 encounters have been described in the literature, all of which are isolated to small series or case reports.3-6 Although current expert opinion has reinforced anticoagulation as initial therapy, the indications for and type of operative intervention are less clear. Historically, open surgical intervention was reserved for favorable operative candidates in the setting of concerning morphologic features (ie, mobile thrombi, large thrombi, recurrent embolism, etc) or those that failed to resolve with medical management.3,6,7 Advancement of endovascular techniques and devices provides a minimally invasive alternative to patients otherwise deemed poor surgical candidates. Reported is a case study and review of current literature surrounding the endovascular management of symptomatic thoracic aortic mobile thrombi (TAMT).
Case Report
exclusion of acute coronary syndromes, evaluation included computed tomography (CT), revealing a large ‘‘saddle’’ thrombus in the origin of the superior mesenteric artery (SMA; Figure 1). Following systemic anticoagulation with heparin, she was taken emergently to the operating room. Access was accomplished via the left brachial artery, and a 7F/80 cm sheath was advanced to level of the L1 vertebra. The SMA was cannulated, and mechanical thrombectomy was performed with a catheter-directed rheolytic/thrombolytic system (AngioJet; MEDRAD Inc, Warrendale, Pennsylvania). Following successful thrombolysis, a 7 22 mm2 balloon expandable stent (iCast; Atrium Medical Corp, Hudson, New Hampshire) was placed within the origin of the SMA and flared (Figure 2). The distal vessels were treated with papaverine. Completion angiography demonstrated return of flow to all major branches and she was returned to the intensive care unit (ICU) for observation. Within the next 24 hours, she developed class IIB ischemia of her left lower extremity. Concern for an additional embolic event necessitated urgent operative exploration and confirmed
1
Patient is a 77-year-old African American female who presented with a primary complaint of severe upper abdominal pain of approximately 48 hours duration. Cardiovascular risk factors included coronary artery disease, hypertension, hyperlipidemia, obesity, and remote smoking history. Following
Department of Vascular Surgery, San Antonio Military Medical Center, Ft Sam Houston, TX, USA Corresponding Author: Daniel J. Scott, Department of Vascular Surgery, San Antonio Military Medical Center, 3851 Roger Brooke Dr, Ft Sam Houston, TX 78234, USA. Email: [email protected]
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
Scott et al
247
Figure 1. Contrast-enhanced computed tomography (CT) demonstrating ‘‘saddle’’ thromboembolism of the superior mesenteric artery.
by angiography (Figure 3). Via open femoral cutdown, balloon thrombectomy was performed. Clot was returned from both superficial and deep femoral arteries and was sent for pathology review. Return of backbleeding and distal signals were demonstrated and the patient returned to the ICU. Due to concern for recurrent embolism, source workup included transthoracic echocardiography with no demonstrable abnormality. Inability to clear her aortic root and arch, however, prompted further evaluation with transesophageal echocardiography (TEE). A large atheroma with associated mobile thrombus in the descending thoracic aorta was demonstrated just distal to the right subclavian origin (Figure 4, Video 1). Given the location of the atheroma, mobile features, and recent embolic events, it was deemed amenable to exclusion by stent graft placement. The patient returned to the operating room, her left radial artery was accessed, and a flush/pigtail catheter was advanced into the aortic arch. The right common femoral artery was additionally accessed, dilated, and an 11F sheath maintained. An extra-stiff guidewire was advanced to the aortic root and intravascular ultrasound used. A large mobile thrombus was visualized approximately 50 mm distal to the subclavian artery. To achieve at least 30 mm seal, an 80-mm thoracic stent graft device (Zenith TX2; Cook Medical Inc, Bloomington, Indiana) was
Figure 2. Postoperative computed tomography (CT) following successful catheter-directed thromboembolectomy and superior mesenteric artery stent placement.
deployed just distal to the right subclavian orifice. Completion angiography demonstrated exclusion of the atheromatous thrombus (Figure 5). Three days following stent graft exclusion, she was tolerating a diet, maintaining renal function, and demonstrating no additional embolic events. She was discharged on clopidogrel and maximal statin therapy. At 9-month follow-up, a repeat CT angiography (CTA) was performed, which demonstrated continued patency of her left femoral and SMAs. Her thoracic endograft remains in place with appropriate seal, and no evidence of additional thrombi, dissection, stent fracture, or migration.
Discussion Thoracic aortic mobile thrombi are rare sources of distal mesenteric or lower extremity emboli. Risk factors include young age, smoking, and family history of atherosclerotic disease. Nevertheless, the incidence of this disease process is increasing, likely secondary to expanded use of sensitive noninvasive evaluations including TEE, CTA, and magnetic resonance (MR) angiography in further evaluating previously ‘‘cryptogenic’’ emboli.
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
248
Vascular and Endovascular Surgery 48(3)
Figure 3. Left lower extremity angiogram confirming recurrent thromboembolism.
Figure 4. Representative transesophageal echocardiographic image of descending thoracic aortic thrombus.
Several authors have endorsed TEE as a requirement to diagnose TAMT. The real-time evaluation allows for analysis of both morphologic (ie, sessile vs pedunculated) and dynamic (mobile/floating vs fixed) properties of the thrombus, ultimately providing clues on its embolic potential.6-9 In some institutions with the technological capability, MR imaging (MRI)/MR angiography, may also be helpful in this regard, particularly with the additional use of cine-MRI to evaluate the mobility of the thrombus. Since the recognition of this disease process, multiple treatment modalities have been described with varying levels of invasiveness and effectiveness. These approaches include anticoagulation alone,3,6 transfemoral thrombectomy,6 open
Figure 5. Intraoperative (completion) angiogram following successful exclusion with thoracic stent graft.
surgical extirpation,6,7 and aortic replacement.6 In contrast to abdominal aortic sources of embolic thrombi, the use of stent grafts in this manner has only been recently described as a viable option.9,10 Although experiences are currently limited to few case reports (and with resultant reporting bias), the early results have been promising with 100% technical success, no early recurrences, and no wire or device complications (including leak, aberrant placement, migration, or wire complications to include inadvertent embolism; Table 1).9,11-17 Nevertheless, several considerations should be made when approaching these lesions. These include (1) careful management of wires to prevent iatrogenic emboli; (2) use of angiography (via left subclavian) and/ or intravascular ultrasonography to accurately identify and exclude the affected segment of aorta; (3) planning of at least 1 to 2 cm proximal and distal landing zone/overlap; (4) postprocedural evaluation of mesenteric and lower extremity vessels. The etiology of TAMT is relatively enigmatic and often afflicts young patients with nearly normal aortas with absent or limited atheromatous base.5 Multiple factors have been implicated to include hypercoagulable states (including nonaortic malignancy), smoking, steroid use, trauma, drug abuse, heparin-induced thombotic thrombocytopenia, rheumatism, or history of vasculitis.6 Adversaries to an endovascular approach argue lack of tissue diagnosis. While extremely rare, primary aortic malignancy is always a concern, particularly in otherwise young and normalappearing aortas.18,19 Opportunely, most mobile thrombi of the aorta are diagnosed following embolic phenomena of the lower extremity and present an opportunity for histological analysis of representative clot on initial treatment/revascularization. The clot removed from this patient’s initial operation demonstrated
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
249
Downloaded from ves.sagepub.com at University of Manitoba Libraries on June 17, 2015
2010 2011 2004 2012
Wolf et al15 Giovanni et al17 Criado et al9 Current patient
1 2 1 1
1 1 1 1 1 63F 45F/67M 60F 78F
63M 70M 74F 47F 56M
Age
CTA/TTE TEE TEE TEE
TEE/CTA TEE CTA/TTE CTA CTA
Diagnostic Modality 2
Gore TAG (26 100 mm2) Bolton Relay (22 100 mm2)/(34 100 mm2) PTFE/Cordis Palmaz stent (30 100 mm2) Cook Zenith TX2 (28 140 mm2)
LeMaitre EndoFit (40 180 mm ) Gore TAG (34 100 mm2) Gore TAG (37 150 mm2) Gore Excluder (26 100 mm2) Gore TAG (28 100 mm2)
Device
NR Warfarin/warfarin Warfarin Clopidogrel
Clopidogrel Warfarin/ASA Warfarin NR Warfarin
Postoperative Antiplatelet/ Anticoagulation
Ulcerated plaque Ulcerated plaque PT mutation NR Hyperhomocysteine, MTHFR mutation, lupus anticoagulant Atheroma NOS Atheroma NOS Ulcerated plaque Atheroma NOS
Etiology
Abbreviations: TEE, transesophageal echocardiogrphy; PTFE, polytetrafluoroethylene; CTA, computed tomography angiography; ASA, acetylsalicylic acid; PT, prothrombin; MTHFR, methylenetetrahydrofolate reductase; NOS, not otherwise specified. a Device manufacturers: LeMaitre Vascular, Inc, Burlington, Massachusetts; Cook Medical Inc, Bloomington, Indiana; Gore Medical, Flagstaff, Arizona; Cordis Corp, Miami Lakes, Florida; Bolton Medical Inc, Sunrise, Florida.
2008 2008 2005 2008 2007
11
Year # Patients
Saratzis et al Zhang et al12 Fueglistaler et al13 Luebke et al16 Piffaretti et al14
Author
Table 1. Current Reported Experience With Endovascular Management of Mobile Thoracic Aortic Thrombi.a
250
Vascular and Endovascular Surgery 48(3)
no evidence of malignancy on pathology review; therefore, exclusion with stent grafting was able to be performed with confidence of no underlying malignancy. Intra-arterial biopsy has been described in the interventional radiology literature, although the potential for embolic complication is often prohibitively high.20 Instead, preoperative MRI is considered the gold standard imaging modality.19,21 If suspicion for primary malignancy exists, excision and graft replacement is favored over confirmative tissue biopsy. Recurrence rates up to 10% to 20% have been reported following open intervention.3,22 This has led to a recommendation of lifelong anticoagulation following open repair.3 One additional advantage of stent graft exclusion is the ability to obviate lifelong anticoagulation and its inherent morbidity. Once a hypercoagulable state is excluded, antiplatelet therapy alone can be initiated without concurrent anticoagulation.
Conclusion Thoracic aortic mobile thrombi are a rare but significant source of distal emboli. Effective detection and characterization by TEE or cine-MRI help qualify the embolic potential of these previously enigmatic lesions. In contrast to open surgical management, endovascular stent graft exclusion has demonstrated promising results with little morbidity. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material The online video 1 is available at http://ves.sagepub.com/supplemental. Video 1. Real-time transesophageal echocardiogram demonstrating mobility of thoracic aortic thrombus.
References 1. Lord JW Jr, Rossi G Daliana M, Drago JR, Schwartz AM. Unsuspected abdominal aortic aneurysms as the cause of peripheral arterial occlusive disease. Ann Surg. 1973;177(6):767-771. 2. Oliver DO. Embolism from mural thrombus in the thoracic aorta. Br Med J. 1967;3(5566):655-656. 3. Choukroun EM, Labrousse LM, Madonna FP, Deville C. Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 cases. Ann Vasc Surg. 2002;16(6):714-722. 4. Goueffic Y, Chaillou P, Pillet JC, Duveau D, Patra P. Surgical treatment of nonaneurysmal aortic arch lesions in patients with systemic embolization. J Vasc Surg. 2002;36(6):1186-1193. 5. Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromboses of the aortic arch without aortic debris. A transesophageal echocardiographic finding associated with unexplained arterial embolism. The Filiale Echocardiographie de la Societe Francaise de Cardiologie. Circulation. 1997;96(1):288-294.
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