Bare Metal Stenting for Endovascular Exclusion of Aortic Arch Thrombi

Use of Wallstent device as an embolic protection device during stenting of aortic thrombus

Blue toe syndrome can occur due to distal embolization from proximal lesions such as an aortic thrombus. We describe the case of a patient who presented with chronic limb threatening ischemia due to a flow-limiting infrarenal aortic thrombus, with gangrene from distal embolization to the left fifth toe, and was successfully treated with endovascular aortic stent graft insertion. Distal embolization during instrumentation was successfully prevented by using a partially deployed Wallstent (Boston Scientific) as an embolic protection device. The reconstrainable Wallstent device can be considered for distal thromboembolic protection during aortic stenting, in particular, when distal embolization is a concern and commercial devices are not readily available.

Successful Conservative Treatment of a Complicated Aortic Thrombus in a Woman with Factor V Leiden Mutation

Thrombus in the aortic trunk is a rare complication. We report the case of a 63-year-old patient with a factor V Leiden mutation in whom an aortic arch thrombus was discovered accidentally. Conservative treatment was initiated with therapeutic anticoagulation with low-molecular-weight heparin leading to complete thrombus lysis after 3 months but associated shortly after anticoagulation initiation with a large splenic and limited renal infarctions.

Symptomatic Aortic Mural Thrombus Treatment and Outcomes

BACKGROUND

To report results achieved in treatment of symptomatic aortic mural thrombus in a single institution.

MATERIALS AND METHODS

A retrospective analysis of data about 97 patients presenting with acute onset lower limb ischemia (Rutherford stage II-III), upper limb ischemia, and mesenteric ischemia surgically treated between January 2011 and December 2018 in the Vascular and Endovascular Unit of Foch Hospital (Suresnes, France) was conducted. Only patients affected with primary aortic mural thrombus (PAMT) as source of embolism were included.

RESULTS

A total of 9 patients (mean age 51 years, range 28-69; 55.5%, n 5 men and 44.5% n 4 women) were affected with PAMT. Three (33.3%) patients presented a concomitant renal embolism (22.2% of acute renal failure). Thrombus was located at the level of thoracic aorta (4 patients), visceral aorta (2 patients), or infrarenal aorta (3 patients). PAMT was sessile or pedunculated in 5 (55.5%) and 4 (44.4%) patients, respectively. Treatment consisted of anticoagulation in all patients in association with surgical exclusion of the PAMT, distal thrombectomy alone, or in addition to distal bypass. At a median follow-up of 22 months (range 1-57 months) no patients died, 4 patients (44.4%) recovered well, and 5 patients (55.5%) experienced recurrence/thrombus persistency and needed secondary interventions. The best results and absence of recurrences were achieved in patients undergoing immediate exclusion of the PAMT.

CONCLUSIONS

PAMT is an uncommon source of embolism, and no guidelines are at disposal in its management. An aggressive approach with anticoagulation and exclusion of thrombus seems to be efficacious in preventing recurrences limiting complications and optimizing outcomes.

Outcome of Endovascular Approach for Management of Thoracic Aortic Thrombus

Thoracic aortic thrombus is a rare condition that can be a significant source of distal embolic events. This study details experience on the use of an endovascular technique for the management of thoracic aortic thrombus with a stent graft in 5 cases. Four of the cases were diagnosed with aortic arch thrombus, and 1 was diagnosed with distal descending aortic thrombus. All patients were females with age ranging from 44 to 71 years. Arterial embolism was the main clinical finding in most cases, which involved the upper extremities (n = 1) and cerebral embolism (n = 3), while 1 patient was asymptomatic. All 5 surgeries were considered technically successful with 0 perioperative all-cause mortality. Patients were discharged in a stable condition and were prescribed anticoagulant and antiplatelet medications. During follow-up visits, there were no instances of stent-graft failure or collapse, leak, or distal migration. Furthermore, there was complete resolution of the intraluminal thrombus, and all patients were asymptomatic.

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

Mural thrombus in non-atherosclerotic or aneurysmatic thoracic aorta is a relatively uncommon entity. Currently there is no consensus on the appropriate therapeutic algorithm of its management. We aim to present the current knowledge on the treatment of thoracic aorta mural thrombi (TAMT) in minimally atherosclerotic vessels and we hope that the juxtaposed discussions will shed light on the uncharted waters regarding this rare syndrome. The MEDLINE/PubMed database was searched for publications with the medical subject "aortic mural thrombus" and keywords "thoracic", "embolism", "normal vessel", "minimally atherosclerotic vessel" or "treatment". We restricted our search to English language, till January 2017. The electronic literature search yielded 23 reports that were deemed appropriate for further analysis. Anticoagulation is the standard of care for the treatment of the thrombus whereas surgical and interventional treatment seems to be related with increased mortality and lower recurrence rates. TAMT treatment is controversial. Anticoagulants are the mainstay of treatment but surgery seems to gain ground in several settings as an only therapy or a combined treatment modality. More data are needed on the role of novel oral anticoagulants and endografts.

Endovascular Stent-Grafting of the Ascending Aorta for Symptomatic Parietal Thrombus

PURPOSE

To present stent-graft treatment of parietal thrombus in the ascending aorta.

CASE REPORT

A 64-year-old man with no history of vascular disease developed a right cerebral hemisphere transient ischemic attack and was diagnosed with mural thrombosis of the ascending aorta involving the greater curvature just proximal to the origin of the innominate artery. He was treated for 2 months with anticoagulants, but new imaging studies showed significant increase in the size of the thrombus and an irregular aspect. The thrombus was excluded from the aortic blood flow by deployment of a custom-made stent-graft in the ascending aorta, with embolic protection of the right internal carotid artery. At 6 months, the patient was well, and the thrombus in the ascending aorta appears to be completely excluded by the stent-graft.

CONCLUSION

In highly selected cases, custom-made thoracic stent-grafts may be used for stabilization and exclusion of symptomatic ascending aorta parietal thrombosis to prevent progression and recurrent embolization.