Transesophageal echo-guided endovascular exclusion of thoracic aortic mobile thrombi

Abstract

Mobile luminal thrombus of the descending thoracic aorta is an unusual finding in patients with peripheral embolization. The diagnosis is best made with transesophageal echography (TEE). Traditionally, systemic anticoagulation and selective surgical thrombectomy are standard treatment. We present a case report of recurrent mobile thrombus despite surgical thrombectomy and systemic anticoagulation. We treated it with endovascular exclusion of a descending thoracic aorta emboligenic lesion with an endoluminal stent graft, using simultaneous TEE and fluoroscopic intraoperative guidance. The patient remains symptom-free 9 months after stent-graft implantation. TEE-guided endoluminal exclusion should be considered in treatment of descending thoracic aorta emboligenic lesions.

Editor's Choice – Management of Descending Thoracic Aorta Diseases

“…296 Less invasive surgical approaches have been proposed, including TOE guided trans-aortic and trans-femoral balloon thrombectomy, percutaneous catheter thrombo-aspiration, and TOE guided thrombus exclusion using endovascular covered stents. 298 Endovascular exclusion of the thrombus from the systemic circulation by stent graft deployment is certainly an attractive approach in high risk surgical patients with favourable anatomy, although the possibility of thrombus fragmentation and dislodgement by catheter manipulation should also be considered.…”

Endovascular Management of Idiopathic Proximal Descending Aortic Thrombus after Attempted Medical Management

“…Choukroun et al [8] recommends a treatment period of 15 days with intravenous heparin to a target activated clotting time between two and threefold that of physiologic. With this approach, they reported resolution of the aortic thrombus in 4 of the 9 patients [8][9][10][11][12][13]. Boufi et al [13] reports a similar response rate to intravenous heparin in a separate case series.…”

“…Criado et al [12] first described the use of stent grafts for endovascular exclusion of thoracic aortic mural thrombi. Boufi et al had seven patients successfully undergo endovascular stent graft exclusion of aortic thrombus with no complications or deaths at 30 days [13].…”

Endovascular treatment for mobile thrombus of the thoracic aorta

“…Similar to open surgery, SG can exclude the thrombus, treats the potential underlying cause of the thrombotic lesion by covering the atherosclerotic aortic wall, and allows the combination of the thoracic endovascular procedure with a peripheral embolectomy through the same remote access. Criado et al [9] used a SG to exclude a TAMT, after a failed open thrombectomy; previously, Fueglistaler et al [10] used a SG to treat a TAMT of the distal aortic arch. Our experience is consistent with these previous cases as the patient was last seen 6 months later with no recurrent signs of TAMT or symptoms of embolization.…”