Endovascular Management of a Mobile Thoracic Aortic Thrombus Following Recurrent Distal Thromboembolism

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.

Contemporary management of symptomatic primary aortic mural thrombus

“…3,14 Covered stent graft exclusion of aortic mural thrombus has been described as an effective option in contemporary series. 1,2,12,13,30 In our experience, eight patients with type II PAMT presented with either severe limb ischemia or bowel ischemia, or both (Table I). Given the risks involved with open surgical thrombectomy, all patients were considered for stent grafting either during or after addressing of the acute event (eg, peripheral thromboembolectomy).…”

“…Type IIa has been the most common type of PAMT described in the past. [1][2][3][4][5][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] The junction of the distal aortic arch and descending thoracic aorta has been shown to have a predilection for aortic mural thrombus, although its exact cause is not known. The possibility of an embryologic defect at the aortic isthmus and shear, bending, and torsion stresses 26 attributed to aortic trauma during blunt chest injuries have been described.…”

Successful thrombectomy for coronary embolism likely due to floating aortic plaque in ascending aorta

“…Recently, endovascular stent graft has been reported not only in surgical treatment for mobile thoracic aortic thrombus [11]. Because the mobile plaque existed in the ascending aorta and plaque volume is small in this case, we did not select the surgery including the stent grafts (risk of surgical therapy is higher in the ascending aorta than in the descending aorta).…”

A critical reappraisal of the treatment modalities of normal appearing thoracic aorta mural thrombi

“…Surgical intervention (open/endovascular), as primary or adjuvant treatment, is mainly indicated in cases where conservative treatment has failed or is contraindicated. Reports of open surgical treatment of symptomatic mobile thrombus with thrombectomy only (10,52,54) or graft replacement (19), is performed through a thoracotomy (10,19,52,54) or trans-abdominally (10), with simple aortic clamping or left atrial to femoral artery bypass (55). These interventions are associated with high mortality rate (2.6-5.7%) but lower than conservative treatment alone (6.2%) (45,53).…”

“…In this frame, angiography can be used to map the affected aortic segment and design the appropriate proximal and distal landing zones of the endograft. Finally, it is crucial to evaluate the mesenteric and lower extremity vessels after the procedure (55). Unfortunately, endovascular treatment does facilitate the histological analysis of the thrombus to offer insights about its origin, including malignancy.…”