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European Journal of Echocardiography 2008 9(1):178-180; doi:10.1016/j.euje.2007.07.012
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

Massive thrombus in the aortic arch: a 59-year-old lady with an unknown familial predisposition to vascular thrombosis

John O'Sullivan*, David Kerins and Carl Vaughan

Mercy University Hospital, Cork, Ireland

Received 23 March 2007; accepted after revision 22 July 2007; online publish-ahead-of-print 24 September 2007.

* Corresponding author. Tel: +353 87 6206941; fax: +353 21 4276341. E-mail address: osull.john{at}gmail.com


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The following is an account of a 58-year-old lady who presented to our institution with two episodes of acute limb ischemia: one upper, which required embolectomy; and one lower, which required a below knee amputation. We subsequently performed transesophageal echocardiography (TOE), which revealed very large mobile echogenic masses adherent to the wall of her aortic arch, described below.

Keywords: Aortic arch; Thrombosis; Embolisation; Amputation

This 58-year-old lady was referred from a nearby Regional Hospital to the vascular surgeons in our institution with an acutely ischemic left upper limb. She subsequently underwent emergent removal of a brachial and axillary artery embolus, confirmed by histology. An intra-operative angiogram confirmed her native vessel was healthy. Three months previously, she had presented to the referral hospital with an acutely ischemic left lower limb. Despite popliteal embolectomy and bypass procedure she eventually required an above knee amputation. Considering that she presented with an acute ischemic limb on two separate occasions, and her native brachial and axillary vessels were healthy, it was reasonably suspected that the origin of the emboli was her heart. She was referred to the cardiology team for advice.

A trans-thoracic echocardiogram (TTE) was technically difficult due to body habitus, but revealed mild LVH with good systolic function, mildly enlarged left atrium, with normal Doppler velocities through the aortic and mitral valves. No intramural thrombi were seen, but the study was sub-optimal. A 48 h holter rhythm monitor revealed sinus rhythm throughout. We consulted the hematology service and they suggested a full thrombophilia screen. The complete thrombophilia screen including factor II prothrombin gene, factor V leiden gene, lupus anticoagulant (dilute Russell viper venom test [DRVVT], antiphospholipid antibodies [including cardiolipin IgG antibodies and β2-glycoprotein antibodies]), antinuclear antibodies, anti-mitochondrial antibodies, smooth muscle cell antibodies, reticulin antibodies, anti-LKM antibodies, microsomal agglutination antibodies, Actin FSL, activated protein C resistance (APCR), was negative. Platelet aggregation assay and platelet function testing were normal. Homocysteine and Methionine levels were normal. Renal, liver and thyroid function were normal. Hemoglobin and white cell count were normal, platelets were mildly elevated. A screen for occult malignancy was negative: tumor markers were negative; bilateral mammograms revealed no evidence of malignancy, or any suspicious lesions; CT thorax/abdomen/pelvis revealed no evidence of malignancy.

The patient had 14 siblings in all: eight brothers, one of whom asphyxiated as a child, one of whom was a stillbirth, and one who died aged 69. She had six sisters, all alive. The patient's family history revealed a significant history of deep venous thrombosis (DVT): one brother in his 60s who died at 69, two sisters at ages 56 and 62 had a DVT, as did her daughter at age 34. Three other brothers also had a cerebrovascular accident (CVA) aged 51, 52, and 65. The brother aged 52 also had an MI in his late forties. One other sister aged 64 had two CVAs at 60 years of age. Thus, the inheritance pattern if any would seem to be autosomal dominant, perhaps with incomplete penetrance.

We proceeded to transesophageal echocardiogram (TOE) to exclude potential sources of embolism: we out-ruled patent foramen ovale (PFO) with an agitated saline (‘bubble’) study, and we imaged the proximal aorta. This revealed mobile echogenic masses in the descending aorta beginning at 30 cm from the incisors and extending proximally to the arch. These masses were homogenous in consistency and adherent in part to the aortic wall, which most likely represented thrombosis (see Figures 1 and 2). The agitated saline study was negative. The rest of the study did not reveal any anomaly apart from mild mitral regurgitation. The left atrial size was normal. The left atrial appendage was normal with no thrombus, and normal velocities. The interatrial septum was intact. The aortic valve was trileaflet with mild fibrocalcific change. The aorta at the sinuses of valsalva was normal. The ascending aorta was normal. There was mild left ventricular hypertrophy. Left ventricular systolic function was normal with an ejection fraction of 60%.

Interestingly, she also did not have many risk factors for coagulopathy: she was a life-long nonsmoker, with no history of thrombosis; she was not on estrogen supplementation. The aorta surrounding the thrombus was normal in appearance and free from atheroma.

We felt the question of etiology was not properly defined. Therefore, we referred the patient to a consultant hematologist colleague with an interest in vascular thrombosis. The patient was commenced on oral anticoagulation therapy lifelong with a target international normalized ratio (INR) of 3.5–4.0. We planned follow up with a further TOE to monitor progress.


Figure 1
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  		Figure 1 TOE image of thrombi in short axis.

 


Figure 2
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  		Figure 2 TOE showing thrombi in long axis.

 

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Supplementary material associated with this article can be found in the online version.


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  1. Oliver DO. Embolism from mural thrombus in the thoracic aorta. Br Med J (1967) 9 9;3:655–6.[Free Full Text]
  2. Williams GM, Harrington D, Burdick J, White RI. Mural thrombus of the aorta: an important, frequently neglected cause of large peripheral emboli. Ann Surg (1981) 12;194:737–44.[Web of Science][Medline]
  3. Christiaens L, Allal J, Corbi P. Thrombus in a normal sinus of valsalva: angiographic, multiplane transoesophageal echocardiographic, surgical findings. Heart (1996) 9;76:287–8.[Abstract/Free Full Text]
  4. Sheikhzadeh A, Mitisch R, Stierle U. Systemic embolism. Eur Heart J (1993) 1;14:143–4.[Free Full Text]
  5. Lozano P, al Mousa E, Wei CF, Thandroyen FT. Images in cardiovascular medicine. Intra-aortic thrombus producing embolic arterial vascular disease. Circulation (1996) 4 1;93:1471.[Free Full Text]
  6. Kolvekar SK, Chaubey S, Firmin R. Floating thrombus in the aorta. Ann Thorac Surg (2001) 9;72:925–7.[Abstract/Free Full Text]
  7. Choi JB, Choi SH, Kim NH, Jeong JW. Floating thrombus inthe proximal aortic arch. Tex Heart Inst J (2004) 31:432–4.[Web of Science][Medline]
  8. Geha AS, El-Zein C, Massad MG, Bagai J, Khoury F, Evans A, et al. Surgery for aortic arch thrombosis. Thorac Cardiovasc Surg (2004) 6;52:187–90.[CrossRef][Web of Science][Medline]
  9. Schwartzbard A, Freedberg RS, Kronzon I. The value of repeat transesophageal echocardiography in the evaluation of embolism from the aorta. J Am Soc Echocardiogr (2000) 12;13:1124–6.[CrossRef][Web of Science][Medline]
  10. Hisagi M, Morota T, Endo M, Taketani T, Takamoto S. Floating thrombus in the ascending aorta. Gen Thorac Cardiovasc Surg (2007) 1;55:38–40.[CrossRef][Medline]
  11. Bruno P, Massetti M, Babatasi G, Khayat A. Catastrophic consequences of a free floating thrombus in ascending aorta. Eur J Cardiothorac Surg (2001) 1;19:99–101.[Abstract/Free Full Text]
  12. Ockert S, Schumacher H, Böckler D, Schwarzbach M, Rotert H, Allenberg JR. Intraluminal mass lesions of the thoracic aorta. Chirurg (2004) 12;75:1215–20.[CrossRef][Web of Science][Medline]
  13. Reber PU, Patel AG, Stauffer E, Müller MF, Do DD, Kniemeyer HW. Mural aortic thrombi: an important cause of peripheral embolization. J Vasc Surg (1999) 12;30:1084–9.[CrossRef][Web of Science][Medline]
  14. Kocica MJ, Panic G, Lackovic V, Obrenovic-Kircanski B. ‘Butterfly- shaped’ thrombus in the ascending aorta. Eur J Cardiothorac Surg (2006) 12;30:936. [Epub 2006 Oct 19].[Free Full Text]
  15. Belkin RN, Chaudhry S, Chung J, Kay RH, Pooley RA, Shah P, et al. Detection of ascending aorta thrombi with transesophageal echocardiography in patients with systemic embolization. Am Heart J (1995) 12;130:1294–5.[CrossRef][Web of Science][Medline]
  16. Laraudogoitia E, Evangelista A, García del Castillo H, Lekuona I, Palomar S, González-Alujas T, et al. Thrombus in the thoracic aorta as cause of peripheral embolism diagnosed using transesophageal echocardiography. Rev Esp Cardiol (1997) 1;50:62–4.[Web of Science][Medline]
  17. Crawford J, Alam M, Butler M, Ghafari G, Shepherd A. Systemic embolization by a thrombus in a apparently normal aorta detected with transesophageal echocardiography. J Am Soc Echocardiogr (1997) 6;10:569–72.[CrossRef][Web of Science][Medline]
  18. Lozano P, Gomez FT, Julia J, M-Rimbau E, Garcia F. Recurrent embolism caused by floating thrombus in the thoracic aorta. Ann Vasc Surg (1998) 11;12:609–11.[CrossRef][Web of Science][Medline]
  19. Kalangos A, Baldovinos A, Vuille C, Montessuit M, Faidutti B. Floating thrombus in the ascending aorta: a rare cause of peripheral emboli. J Vasc Surg (1997) 7;26:150–4.[CrossRef][Web of Science][Medline]
  20. Vaduganathan P, Ewton A, Nagueh SF, Weilbacher DG, Safi HJ, Zoghbi WA. Pathologic correlates of aortic plaques, thrombi and mobile "aortic debris" imaged in vivo with transesophageal echocardiography. J Am Coll Cardiol (1997) 8;30:357–63.[Abstract]
  21. Sodian R, Bauer M, Weng YG, Siniawski H, Koster A, Hetzer R. Floating nonocclusive thrombus in the ascending aorta. Ann Thorac Surg (2002) 8;74:588–90.[Abstract/Free Full Text]
  22. Hirota J, Akiyama K, Taniyasu N, Iba Y. A case of protruding atherosclerotic plaque with mobile projections in the sinotubular junction. Kyobu Geka (2001) 11;54:1059–61.[Medline]
  23. Brandt RR, Neuzner J, Roth M, Bauer EP, Klovekorn WP, Hamm CW. Peripheral arterial embolism originating from a thrombus in the ascending aorta. Thorac Cardiovasc Surg (2001) 4;49:122–4.[CrossRef][Web of Science][Medline]
  24. Labanti G, Urbinati S, Grepioni A, Pinella GL, Pinelli G. Complicated atherosclerosis of the ascending aorta as a cause of recurrent cerebral embolisms in young adulthood. G Ital Cardiol (1998) 12;28:1418–21.[Medline]
  25. Dressler FA, Craig WR, Castello R, Labovitz AJ. Mobile aortic atheroma and systolic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke. J Am Coll Cardiol (1998) 1;31:134–8. Comment in: J Am Coll Cardiol. 1999 Mar;33:899.[Abstract/Free Full Text]
  26. Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromboses of the aortic arch without aortic debris. A transesophageal chocardiographic finding associated with unexplained arterial embolism. The Filiale Echocardiographie de la Societe Francaise de Cardiologie. Circulation (1997) 7 1;96:288–94.[Abstract/Free Full Text]
  27. Mochizuki S, Takayama S, Nishiyama T, Kakizawa H, Shikaura K, Sakamoto M, et al. Two cases of protruding atherosclerotic plaque with mobile projections in the aortic arch. Intern Med (1993) 10;32:777–80.[Web of Science][Medline]
  28. Bansal RC, Pauls GL, Shankel SW. Blue digit syndrome: transesophageal echocardiographic identification of thoracic aortic plaque-related thrombi and successful outcome with warfarin. J Am Soc Echocardiogr (1993) 6:319–23. 5–6.[Medline]
  29. Blackshear JL, Jahangir A, Oldenburg WA, Safford RE. Digital embolization from plaque-related thrombus in the thoracic aorta: identification with transesophageal echocardiography and resolution with warfarin therapy. Mayo Clin Proc (1993) 3;68:268–72.[Web of Science][Medline]

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