Symptomatic Thoracic Aorta Mural Thrombus

Graham Roche-Nagle; Douglas Wooster; George Oreopoulos

Disclosures

Vascular. 2010;18(1):41-44. 

In This Article

Case Report

A 42-year-old man of Pakistani origin presented with pain and pallor of sudden onset in his left upper limb. His past history included hypertension, hypercholesterolemia, sleep apnea, diabetes mellitus (type 2), and two previous deep venous thromboses owing to an underlying factor V Leiden mutation. He had no previous medical history of arrhythmia, ischemic heart disease, or stroke; was a smoker for 15 years; and had a body mass index of 28. Prior to his presentation, he was given conflicting advice regarding his requirement for ongoing anticoagulation and discontinued it. Physical examination revealed cooled and mottled fingers in the left hand. His left axillary pulse was palpable, but distally in the left arm, no pulses were present. The examination was otherwise unremarkable.

A successful left brachial embolectomy was performed with postoperative angiography, and the patient was anticoagulated. Investigations were performed to discover a potential source of the embolus. The resting electrocardiogram and Holter monitoring for 24 hours disclosed a normal sinus rhythm without any pathologic findings. The transthoracic echocardiographic examination showed no structural or functional cardiac abnormalities. Computed tomographic (CT) angiography of the thoracic aorta revealed a significant mural thrombus extending into his left subclavian artery from his descending aorta (Figure 1), and this was confirmed by transesophageal echocardiography (Figure 2). A full hypercoagulable workup (antiphospholipid antibodies, protein C, protein S, antithrombin, factor V Leiden, prothrombin G20210A mutation, and homocysteine) was repeated in consultation with our hematology service, and a factor V Leiden mutation was the only abnormality detected. The case was discussed with our cardiac surgery colleagues, and plans were made to proceed with a left thoracotomy and thrombus removal from the arch under circulatory arrest and cardiopulmonary bypass. Prior to that surgery being carried out, the patient suddenly embolized to his left lower limb and developed an acutely ischemic limb requiring popliteal artery embolectomy. Repeat CT angiography of his thorax revealed that the thrombus in his aorta was absent and had embolized to his leg. Thus, our plans for thoracotomy and thrombus extraction were cancelled, and his anticoagulation continued. His postoperative course was complicated by development of a delayed compartment syndrome 1 week following the popliteal embolectomy, which required fasciotomies. The patient was discharged with lifelong anticoagulation.

Figure 1.

Axial, sagittal, and coronal computed tomographic thoracic angiographic images revealing a thrombus involving the proximal 3 cm of the left subclavian artery and extending 3 cm caudally into the thoracic aorta.

Figure 2.

Transesophageal echocardiography revealed a pedunculated mobile mass arising from the descending aorta (arrow).

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