Contemporary management of symptomatic primary aortic mural thrombus.

OBJECTIVE: Primary aortic mural thrombus (PAMT) is an uncommon condition but an important source of noncardiogenic emboli with a difficult diagnosis and a high rate of complications, including high mortality. We report our experience of thromboembolic disease from PAMT and review its contemporary management. METHODS: Retrospective analysis of prospectively collected data of all patients who presented with acute occlusion of a limb or visceral vessels between January 2011 and September 2013 was performed. RESULTS: A total of 88 patients presented with acute occlusion of the extremities or visceral arteries. All underwent extensive evaluation for the possible source of the embolism. Of these 88 patients, 19 patients (mean age, 41.2 years; male:female ratio, 1:2.1) were found to have aortic mural thrombus as the source of distal embolism. Thrombus was located in the thoracic aorta in 10 patients, in the perivisceral aorta in three patients, and in the infrarenal aorta in six patients. Thrombus in the thoracic aorta was treated with stent grafts in four patients, bare metal stents in three patients, and anticoagulation alone in two patients. In the suprarenal abdominal aorta, all three patients underwent trapdoor aortic thrombectomy. Infrarenal aortic thrombus was managed by aortobifemoral embolectomy in two patients, aortic stenting in two patients, surgical thrombectomy in one patient, and anticoagulation alone in one patient. Successful treatment, defined as freedom from further embolic events or recurrence of thrombus, was achieved in 14 of 19 patients (76.4%) with a mean follow-up period of 16.2 months (range, 2-28 months). There were four (21%) thrombus-related deaths, all due to primary thromboembolic insults. One patient needed a below-knee amputation because of a recurrent thrombotic episode. CONCLUSIONS: Symptomatic PAMT is an uncommon but important source of noncardiogenic embolus. It appears to occur more frequently in young women. Endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with either stent grafts or closed-cell metal stents. When thrombus is located adjacent to visceral vessels, it should be managed with an open trapdoor thromboembolectomy.

Ischemic brachial artery entrapment syndrome by supracondylar humeral bony spur.

Medial supracondylar spur from the humerus is a rare cause of neurovascular pain of the upper extremity. The spur typically entraps the brachial artery and median nerve, resulting in compression-related symptoms. In advance stages, compression could lead to endothelial damage and thrombotic occlusion of brachial artery. Spur is also associated with an anomalous higher insertion of the pronator teres muscle, which could result in multilevel entrapment of the brachial artery. We report a patient with acute upper limb ischemia secondary to brachial artery compression and distal embolization from a medial supracondylar spur and anomalous attachment of the pronator teres. The entrapped brachial artery and median nerve were released by resection of the spur and of the anomalous belly of the pronator teres with thrombectomy of brachial artery.

Endovascular management of iatrogenic carotid-jugular fistula presenting as congestive heart failure.

Carotid-jugular arteriovenous fistula (C-J AVF) after inadvertent carotid puncture during internal jugular vein puncture is a rare entity. Previously, majority of reported cases of CJAVF were identified during inadvertent arterial puncture and managed as emergency. We report a delayed presentation of congestive cardiac failure following multiple attempts at securing an internal jugular venous access for dialysis 3 months prior to diagnosis. Carotid-jugular fistula was identified during workup and was successfully treated by endovascular technique with a covered stent.