The Challenge of Managing a Primary Aortic Mural Thrombus: Outcomes and Technical Considerations

Background:  Embolization to multiple arterial beds associated with primary aortic mural thrombus (PAMT) could result in high morbidity and mortality. There are no recommendations to dictate the best management. This study aims to describe our experience in managing this rare disease. Methods:  A retrospective review of all patients affected by PAMT treated at our institution between January 2015 and December 2021 was performed. Recorded data included demographics, prothrombotic risk factors, imaging findings, clinical presentation, and treatment. Primary outcomes comprised thrombus recurrence, major amputation, and death. Results:  Thirteen patients with PAMT have been included. The median age was 52 years (36-68 years), and the male/female ratio was 1:1.6. The diagnosis of PAMT was made by computed tomography angiography (CTA) in all cases. Prothrombotic conditions were identified in 92% of cases, and most patients (92%) had thoracic PAMT. The most common presentation was acute limb ischemia after thrombus embolization (85%), requiring surgical revascularization. Anticoagulation was promptly started in all patients. Two patients developed heparin-induced thrombocytopenia. Recurrence of embolization/thrombosis was observed in 54% of patients; two underwent endovascular thrombus exclusion with a stent graft. We identified one PAMT-related death and one major amputation with a median follow-up time of 39 months (12-64 months). Conclusion:  Anticoagulation alone as initial therapy could completely resolve PAMT but is associated with high embolization recurrence. Thoracic endovascular aortic repair is feasible and could prevent additional embolization. However, the criteria for its use as a first-line therapy still need to be defined. Our study highlights the importance of closely monitoring these patients.

Management of Spontaneous Aortic Thrombus Following Cisplatin-Based Chemotherapy in Urothelial Cancer: A Case Report

Spontaneous aortic thrombosis is exceedingly rare, and optimal treatment remains uncertain. We present an unusual case of a spontaneous aortic thrombus at the renal artery level in a patient undergoing active cisplatin treatment for urothelial carcinoma. Management included catheter-directed thrombolysis followed by thrombectomy. An open cutdown was performed on the left common femoral artery (CFA), with right groin access via a 6-Fr sheath. Clamping of the left superficial and deep femoral arteries, along with balloon occlusion of the right common iliac artery, prevented distal embolization. A Coda balloon introduced via direct left CFA puncture with a 20-Fr sheath was positioned above the aortic thrombus. After inflation, clots were trawled to the sheath, "sandwiching" the clots before removal of the balloon and sheath via the left groin. Post-operatively, the patient recovered well and received continued therapeutic anticoagulation.

A Ticking Time Bomb: A Case of Floating Distal Aortic Arch Intraluminal Thrombus

Aortic arch thrombus is a rare entity that can result in catastrophic sequelae. This is a case report of a 65-year-old female patient who presented with chest pain that started one day prior to arrival at the emergency department. Acute coronary syndrome (ACS) and pulmonary embolism (PE) were ruled out. A filling defect at the distal aortic arch evident on chest computed tomography angiography (CTA) was confirmed to be a floating distal aortic arch thrombus on transesophageal echocardiogram (TEE). There was no evidence of an underlying aneurysm, dissection, or significant atherosclerosis. The patient was considered to be at high risk for surgical intervention, hence, a decision was made to start the patient on chronic anticoagulation with direct oral anticoagulants (DOACs). A follow-up CTA three months later showed total resolution of the thrombus. The report highlights this treacherous pathology and provides an overview of the predisposing factors, radiologic findings, as well as management strategies for floating aortic arch thrombi.

Non-diseased aortic mural thrombus presenting with acute limb ischaemia

We present a case of a thoracic aortic mural thrombus (AMT) in a non-atherosclerotic and non-aneurysmal aorta that presented with acute limb ischaemia. AMT in a non-diseased aorta without an underlying hypercoagulable disorder is rare. The AMT in our patient was managed with anticoagulation, which resolved on a 5-month follow-up CT scan. This provided us an opportunity to discuss the successful medical management of an AMT, to review the literature on the management of AMT and to add to the literature on a rare presentation of an AMT.

A review of aortic thrombosis in COVID-19 infection

Aim: As the novel coronavirus disease 2019 (COVID-19) pandemic impacts the global healthcare system, evolving data show increased frequency of arterial and venous thromboembolism among patients with COVID-19 infection. Aortic thrombus is a rare thrombotic event with a wide spectrum of clinical manifestations and potential catastrophic complications. This study aimed to elucidate the clinical manifestations, diagnosis and treatment dilemmas of aortic thrombus with COVID-19 infection and raise awareness among frontline medical providers. Aortic thrombosis is rare, but if not considered early in the course of COVID-19 infection, the data suggest that the diagnosis will probably not be made until potentially serious complications arise. Methods: Literature review was conducted between November 1, 2019, and November 14, 2020, on PubMed and Embase to identify publications regarding aortic thrombosis among COVID-19 cases. Results: Most of the patients were male with a median age of 67 years, and had comorbidities (most commonly hypertension, dyslipidemia and diabetes mellitus). In our study, underlying atherosclerosis, a common risk factor for aortic thrombus, was identified among 56% of the patients. Aortic thrombus was symptomatic in 62% of these patients and most commonly manifested itself as acute limb ischemia (46%), whereas 30% of cases were found incidentally during the investigation of elevated inflammatory markers or increased oxygen requirement. Treatment was individualized given the lack of established guidelines for aortic thrombus, including anticoagulation, systemic and catheter directed thrombolysis, and surgical thrombectomy. Overall mortality was found to be 30% in our study. Conclusions: Although rare, aortic thrombus has high morbidity and mortality, and can present without any symptoms or underlying aortic disease. Aortic thrombosis is rare, but if not considered early in the course of COVID-19 infection, the data suggest that the diagnosis will probably not be made until potentially serious complications arise.

Management of an acute cerebral embolic infarct with thrombolysis and mechanical thrombectomy in the presence of an aortic arch floating thrombus

An aortic arch floating thrombus is a rare cause of embolic ischaemic cerebral infarction. Previously, thrombolysis or mechanical thrombectomy has been used to treat acute cerebral infarction in this context; however, combination therapy using both modalities is yet to be published. The optimal management of aortic arch floating thrombi is debated. Endovascular removal, thrombolysis, vitamin K antagonists and recently, direct oral anticoagulants have been utilised to treat aortic arch floating thrombi. Herein, we highlight the case of a patient presenting with dense hemiparesis, dysphasia and chest pain. CT imaging revealed a left middle cerebral artery thrombus and concurrent aortic arch floating thrombus. He was successfully treated with acute thrombolysis and subsequent mechanical thrombectomy of the cerebral thrombus resulting in resolution of his neurological symptoms. Repeat imaging demonstrated persistence of the aortic arch floating thrombus despite thrombolysis. The aortic arch floating thrombus was managed successfully with direct oral anticoagulant therapy.

Case of right ventricular and aortic thrombi in a patient with severe COVID-19

Emerging evidence suggests that novel COVID-19 is associated with increased prothrombotic state and risk of thromboembolic complications, particularly in severe disease. COVID-19 is known to predispose to both venous and arterial thrombotic disease. We describe a case of a 61-year-old woman with history of type II diabetes, hypertension and hyperlipidaemia who presented with dry cough and acute abdominal pain. She was found to have a significantly elevated D-dimer, prompting imaging that showed thrombi in her right ventricle and aorta. She had rapid clinical deterioration and eventually required tissue plasminogen activator with subsequent durable clinical improvement. This case highlights a rare co-occurrence of venous and arterial thrombi in a patient with severe COVID-19. Further studies are needed to clarify the molecular mechanism of COVID-19 coagulopathy, the utility of D-dimer to predict and stratify risk of thrombosis in COVID-19, and the use of fibrinolytic therapy in patients with COVID-19.

Off-label intravenous thrombolysis for early recurrent brain embolism associated with aortic arch thrombus

Safety data of intravenous thrombolysis (IVT) in presence of aortic arch thrombus is scant. Furthermore, IVT is debatable in patients with prior recent stroke. We present a 51-year-old woman with recurrent major infarction 5 days after a minor left MCA territory stroke. She had a floating aortic arch thrombus and she was treated safely and effectively with off-label IVT. Patients with small infarct volumes and mild/no residual neurological deficits after an initial stroke might be considered for IVT in case of early recurrence. IVT may be reasonable in a context of acute severely disabling stroke associated with aortic arch thrombus.

A novel approach to percutaneous aortic thrombectomy

Aortic mural thrombus in the absence of underlying aortic disease is rare and results in a risk of distant arterial embolization that can result in limb loss or other end organ damage. Current management involves open surgery, anticoagulation, and systemic thrombolysis; however, each carries inherent risks. We report the case of aortic thrombus with distal emboli in two patients, a 56-year-old man and a 68-year-old man, neither with underlying aortic pathology and both presenting with limb threatening ischemia. We performed percutaneous mechanical thrombectomy using the FlowTriever System (Inari Medical, Irvine, Calif) with successful removal of the aortic thrombus in both patients.

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.

Construction of a novel Staphylokinase (SAK) mutant with low immunogenicity and its evaluation in rhesus monkey

The heterologous nature of SAK, a thrombolytic drug, elicits high titers of neutralizing antibodies, which limits its clinical use. Here, we aim to establish a SAK mutant with equivalent activity to the wild type but reduced antigenicity, which may allow for multiple injections. Biosun software was used to predict SAK antigenic epitopes, and several main epitopes were modified by gene deletion and mutation. Ten SAK mutants were constructed, and their thrombolytic activity and immunogenicity were analyzed in vitro. SAK6, with a high expression level (45%), similar thrombolytic activity, and lower antibody reaction, was chosen for in vivo analysis in rhesus monkey. In the nearly 8-month experimental period, the antibody level of the SAK6 group was significantly lower than that of the SAK group. Moreover, only 5% of SAK activity was retained, whereas 75.6% of SAK6 activity was retained after incubating with respective antiserum. Overall, these results demonstrated that SAK6, established through comprehensive site-directed mutagenesis program, had identical thrombolytic activity to SAK, low immunogenicity, and less side effects, demonstrating its efficient clinical potential for thrombus disease.

Complete resolution of extensive thrombosis of atheromatous non-aneurysmal descending aorta and pulmonary embolism with warfarin therapy

A 54-year-old man underwent decompressive craniectomy following a stroke. He further developed right lower limb ischaemia, and CT aortography revealed extensive aortic atherosclerotic disease. Urgent embolectomy prevented him from having a major amputation. He subsequently developed pulmonary embolism. This was initially treated with heparin followed by warfarin apart from antiplatelets and statin. A follow-up aortography at 3 months interval showed near complete resolution of atheromatous disease of the aorta. This report raises the possibility that apart from antiplatelets and lipid-lowering agents, anticoagulation may be responsible for resolution of such an extensive atheromatous disease and whether this can be considered as part of regular treatment.

Thrombus in the Right Coronary Sinus of Valsalva Originating From the Left Atrial Appendage Causing Embolic Inferior Wall Myocardial Infarction

Acute myocardial infarction (MI) is commonly a result of coronary atherosclerotic plaque rupture and superimposed thrombus formation. Nevertheless, uncommon causes of MI including embolism from aortic root and ascending aorta mural thrombi must be considered when coronary atherosclerotic disease is not evident. We report a case of a 84-year-old woman who presented with an inferior ST-segment elevation MI. Initial attempts to engage the right coronary artery (RCA) were unsuccessful. Aortic angiography revealed evidence of the left coronary artery ostium with absence of the right coronary ostium or RCA. Probing with a coronary wire where the RCA ostium was presumed to be located yielded resolution of the ST-segment elevation. The RCA was then easily engaged using a guide catheter, and angiographic evaluation showed a smooth vessel with no evidence of coronary artery disease except for abrupt termination of the distal PL2 branch. Contrast-enhanced computed tomography revealed an aortic root thrombus extending into the right coronary sinus of Valsalva and a thrombus in the left atrial appendage. The case reveals RCA embolism from an aortic root thrombus likely originating from the left trial appendage. A conservative approach to treatment with anticoagulation was pursued that resulted in full recovery. A review of the literature revealed that the etiology of aortic root thrombi is proposed to be multifactorial. Prospective randomized studies are needed to demonstrate the best treatment approach, although this appears to be impracticable given the rarity of the disease.

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.

Acute systemic embolism due to an idiopathic floating thrombus of the thoracic aorta: success of medical management: a case report

Background

Idiopathic thoracic aortic mural thrombi are rare. They can be responsible for dramatic systemic embolization. Early treatment is imperative because of their high morbidity and mortality rate.

Case presentation

A 55-year-old previously healthy Moroccan male came in an array of acute right lower limbs pain and abdominal sensibility. Severe systemic embolism involving the lower extremities, spleen, kidney, and digestive tract, due to an idiopathic mural thrombus of the thoracic aorta was diagnosed. He received medical treatment leading to the complete disappearance of the thrombus and the effects caused by the latter.

Conclusions

When faced unexplained peripheral embolization, research for a thrombus of the thoracic aorta should be performed. Medical treatment should be considered for its management, especially in patients with high surgical risk.