Multiple Ascending Aortic Mural Thrombi and Acute Necrotizing Mediastinitis Secondary to Acute Pancreatitis

Abstract

The formation of aortic thrombi is an extremely rare complication of acute pancreatitis. Here we report a case of acute pancreatitis complicated by a paraesophageal pseudocyst, necrotizing mediastinitis, and the formation of multiple thrombi in the ascending aorta. The patient was successfully treated by surgical therapy, which included extensive debridement of the mediastinum and removal of the aortic thrombi under cardiopulmonary bypass. Although esophageal resection was not carried out concomitantly, the lesions were resolved and the patient remained free of complications over 2 years of follow-up care.

Thoracic complications of pancreatitis

“…Pancreatitis is an extremely uncommon etiology for acute mediastinitis, and only a few case reports have described this rare complication. [82][83][84] The underlying mechanism is similar to that leading to internal fistulae with the extension of pancreatic secretions into the mediastinum. It is seen as extensive mediastinal fat stranding on CT. Management is similar to that of internal pancreatic fistula.…”

“…Descending mediastinitis from the infections of the oral cavity and pharynx is less common. Pancreatitis is an extremely uncommon etiology for acute mediastinitis, and only a few case reports have described this rare complication . The underlying mechanism is similar to that leading to internal fistulae with the extension of pancreatic secretions into the mediastinum.…”

“…They managed the patient with octreotide; however, the patient succumbed to his illness. Chong et al reported a patient of alcohol‐related acute pancreatitis who had clinical worsening and progressive mediastinal fat necrosis on CT . This patient also had progressive intraluminal thrombus within the ascending aorta.…”

Aortic mural thrombus visualised on transoesophageal echocardiography

“…Aortic mural thrombus is an uncommon entity that has been reported to develop primarily or secondarily due to multiple underlying medical conditions including acute pancreatitis as in the present case and administration of steroid therapy 1 2. Previous small-scale studies have indicated that conservative therapy, endovascular balloon thrombectomy, endovascular stent graft coverage or surgical removal could be a treatment option whereas no standardised consensus has been established due to the rarity and heterogeneity of this disease 1–4. When we discuss the treatment of aortic mural thrombus, evaluation of thrombus mobility is of fundamental importance in preventing embolic complications.…”

Vascular complications of pancreatitis

“…In cases of small pseudoaneurysms or unclear diagnoses, angiography can be performed. Management of arterial thrombosis in pancreatitis can be complex and is variable depending on the location of the thrombus[ 26 ]. In the cases reviewed, intravascular management with thrombectomy followed by intravenous heparin was used in the patient with superior mesenteric artery thrombosis[ 27 ].…”