In situ ascending aortic thrombus in a patient with metastatic lung adenocarcinoma and no aortic atherosclerosis or cisplatin exposure: a case report.

BACKGROUND: An ascending aortic thrombus is exceedingly rare. Two instances have been reported in the setting of lung cancer, but only after cisplatin use, which is associated with hypercoagulability. We present the first case of a patient with lung cancer who developed an ascending aortic thrombus without structural risk factors or chemotherapy use. CASE: A 60-year-old white female with significant smoking history presented with several weeks of malaise. A chest computed tomography scan revealed a 2.2-cm right upper lobe mass. As an outpatient, right hilar lymph node immunohistochemistry (IHC) samples via endobronchial ultrasound confirmed thyroid transcription factor-1 adenocarcinoma. After the procedure, the patient endorsed dyspnea and was advised to go to the emergency department. A chest computed tomography angiography identified a new 2.4 × 1.1 × 1.1 cm thrombus within the proximal aortic arch. No pulmonary emboli or intrapulmonary shunts were identified. A hypercoagulable workup was negative. Transthoracic echocardiogram was without left ventricular thrombus, akinesis or hypokinesis, left atrial dilation, or intracardiac shunts. A lower extremity ultrasound was negative for deep vein thrombosis. Given the procedural risk, thrombectomy was deferred. The patient was transitioned to enoxaparin, and a repeat computed tomography for resolution is in process. CONCLUSION: To our knowledge, this is the only case detailing an in situ ascending aortic thrombus in the setting of lung cancer, without structural risk factors, chemotherapy use, or other hypercoagulable comorbidities. Optimal management for an aortic thrombus and malignant disease is less clear. Clinicians should be vigilant for unusual arterial thromboses in patients with high metastatic burden.

Repeated acute coronary syndrome caused by a mind-bending mural thrombus in ascending aorta: a case report and review of the literature.

BACKGROUND: Acute coronary syndrome due to coronary artery embolism in the setting of ascending aortic thrombus is an uncommon condition, even rarer when there is no aortic pathology such as aneurysm, severe atherosclerosis, aortic dissection, or thrombophilia (whether inherited or acquired). CASE PRESENTATION: We report a case of a 58-year-old male presented with acute chest pain, electrocardiogram showing non-ST-elevation acute coronary syndrome. The computed tomography angiography of coronary artery revealed a mural thrombus in the proximal part of ascending aorta, located above the left coronary artery ostium, without any aortic pathologies. With the exception of hypertension and cigarette smoking, no other risk factors were identified in this patient that may increase the risk of thrombosis. Given the life-threatening risk of interventional therapy and surgery, the patient determinedly opted for anticoagulant and dual antiplatelet therapy. Then he experienced the reoccurrence of chest pain after 6-day treatment, progressed to anterior and inferior ST-segment elevation myocardial infarction. Coronary artery embolism originating from the ascending aortic thrombus was suspected. Considering the hemodynamic instability of the patient, the medical treatment was continued and bridged to warfarin and aspirin after discharge. Follow-up computed tomography angiography at 6 months showed no obstruction in coronary artery and complete resolution of the thrombus. No thromboembolic events occurred henceforward. CONCLUSIONS: Acute coronary syndrome could be a manifestation of secondary coronary embolism due to ascending aortic thrombus. Currently, there is no standardized guideline for the treatment of aortic mural thrombus, individualized treatment is recommended. When surgical therapy is not applicable for the patient, anticoagulation and dual antiplatelet treatment are alternative treatments that may successfully lead to the resolution of the aortic thrombus.

Endovascular removal of a large free-floating thrombus of the descending thoracic aorta using the AngioVac system.

Free-floating aortic mural thrombus in the minimally diseased or nonaneurysmal aorta is a rare, clinically significant source of peripheral embolism. We describe a 41-year-old woman with a history of left brachial thromboembolectomy who presented atypical chest pain. Computed tomography angiography and transesophageal echocardiography revealed a 14.0 cm × 1.4 cm mobile mass in the proximal descending thoracic aorta. The thrombus was removed through a minimally invasive catheter-based approach using the AngioVac system.

[Embolic stroke due to ascending aortic thrombus in a patient with treatment-resistant ulcerative colitis].

The patient was a 49-year-old man presenting with recurrent melena due to progressive ulcerative colitis. One day, he developed left lower facial weakness and dysarthria, and the next day, he was transferred to our hospital because of muscle weakness in his left upper and lower extremities. On admission, neurological findings revealed left hemiplegia, including left facial palsy, dysarthria, and left hemispatial neglect. Brain MRI with diffusion-weighted image showed a fresh infarction in the right anterior and middle cerebral artery territory. Contrast-enhanced CT showed thrombus in the ascending aorta in addition to occlusion of the right internal carotid artery, suggesting the diagnosis of cerebral infarction with an embolic source in the aortic lesion. The intra-aortic thrombus disappeared after 48th day of antithrombotic therapy. Laboratory findings revealed elevated blood viscosity, proteinase-3-anti-neutrophil cytoplasmic antibody (PR3-ANCA), and ß2GP1-IgG antibodies, suggesting that the cause of the aortic thrombus may be due to elevated blood viscosity and autoantibodies, as well as highly active ulcerative colitis.

Isquemia aguda por trombosis aórtica en COVID-19: A propósito de un caso

Objetivo: Presentar un caso de isquemia aguda por trombosis aórtica en paciente con infección por COVID-19 y exponer la importancia del diagnóstico y manejo oportuno. Introducción: El coronavirus (COVID-19) afecta principalmente al tracto respiratorio, pero presenta predisposición a fenómenos trombóticos y sus complicaciones, siendo una de las más graves la isquemia aguda por trombosis aórtica. Caso clínico: Paciente masculino de 68 años, que cursa con cuadro clínico de neumonía grave por COVID-19, presenta de forma concomitante episodio de trombosis aórtica aguda, resultando con isquemia aguda de extremidades inferiores. Se realizó trombectomía, post procedimiento y asociado a reperfusión, presentó paro cardiorrespiratorio con asistolia sostenida, falleciendo pese a maniobras de reanimación. Conclusión: Pese a las medidas de profilaxis con heparina de bajo peso molecular (HBPM), se deben sospechar y buscar las complicaciones tromboembólicas en pacientes que cursan con esta infección para dar un manejo oportuno y vigilar las complicaciones post quirúrgicas que pueden ser mortales.

Aim: To present a case of acute ischemia due to aortic thrombosis in a patient with COVID-19 infection and explain the importance of diagnosis and timely management. Introduction: The coronavirus (COVID-19) mainly affects the respiratory tract, but it has a predisposition to thrombotic phenomena and its complications, one of the most serious being acute ischemia due to aortic thrombosis. Clinical case: 68-year-old man, coronary heart disease with severe pneumonia due to COVID-19, presents aortic thrombosis, resulting in acute lower extremity ischemia. Thrombectomy was performed, post procedure and associated with reperfusion, presented cardiorespiratory arrest with sustained asystole, died despite resuscitation maneuvers. Conclusion: Despite prophylaxis measures with low molecular-weight heparins (LMWH), thromboembolic complications should be sought in patients with this infection to provide timely management and monitor post-surgical complications that can be fatal.

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.

A Patient With Foot Pain Found to Have Leriche Syndrome: A Case Report and Brief Review of the Literature.

Leriche syndrome, a rare and critical complication of peripheral arterial disease (PAD), affects the distal abdominal aorta (infrarenal) and, similar to PAD, is a result of plaque buildup in the arterial lumen. The Leriche syndrome triad includes claudication in the proximal lower extremity, decreased or absent femoral pulses, and, in some cases, impotence. This article presents a patient with an atypical presentation of foot pain who was subsequently found to have Leriche syndrome. The patient was a 59-year-old female, a former smoker, who presented to the emergency department (ED) with atraumatic, acute right foot pain. All right lower extremity pulses were faintly audible on bedside Doppler. Computed tomography with angiography of the abdominal aorta revealed a Leriche-type occlusion of the infrarenal abdominal aorta and left common iliac and a 10 cm right popliteal arterial occlusion. Pharmacological anticoagulation was initiated by the ED. Definitive treatment in this patient included catheter-directed tissue plasminogen activator lysis to the thrombus on the right and placement of kissing stents in the distal aorta without complication. The patient made an excellent recovery and had a complete resolution of her symptoms. PAD is an omnipresent condition and, when untreated, can result in a myriad of high mortality and morbidity conditions such as Leriche syndrome. Collateral vessel formation can make the symptoms of Leriche syndrome vague and inconsistent, often making early recognition difficult. Optimal outcomes hinge on the clinician's ability to efficiently recognize, diagnose, stabilize, and coordinate multidisciplinary involvement of vascular and interventional radiology specialties. Case reports such as this one help to illuminate some of the more infrequent presentations of Leriche syndrome.

Frozen Elephant Trunk Technique to Treat Extensive Thoracic Aortic Mural Thrombus.

We describe a case report of a 63-year-old man who presented with chronic left-hand weakness and the absence of a pulse in the left arm. Thoracoabdominal computed tomography (CT) revealed an extensive thoracic aortic mural thrombus. Initial anticoagulation therapy did not provide a positive result, so the patient was referred for surgery. Hybrid aortic arch surgery using the frozen elephant trunk technique was performed with excellent early outcomes. A CT performed in the early postoperative period showed that the thrombus was completely excluded from the aortic lumen by the hybrid graft. No thrombus dislodgment was detected. No thrombus recurrence was observed during 19 months of follow-up.

COVID-19-Associated Coagulopathy: Ascending Aortic Thrombus.

The mechanism of arterial thrombosis in coronavirus disease 2019 (COVID-19) is not completely understood and is attributed to the complex interactions of endothelial injury, platelet hyperactivation, and activated pro-inflammatory cytokines. Management strategies may include a combination of surgery and anticoagulation, or anticoagulation alone. A 56-year-old woman with recent COVID-19 infection presented with chest pain and dyspnea. Chest CT angiography (CTA) and aortic magnetic resonance imaging revealed an intraluminal thrombus in the mid ascending aorta. A multidisciplinary team decided on heparin infusion. She was transitioned to apixaban and a three-month interval outpatient CTA revealed complete resolution of the aortic thrombus.

Surgical management of primary aortic thrombus in thoracic aorta.

Background: Primary aortic thrombus (PAT) in the absence of underlying aortic pathology such as atherosclerosis or aneurysm is quite rare and presents with various symptoms related to distal embolization. Treatment options include anticoagulation alone, open surgical thrombectomy, endovascular repair, and a combination of these approaches. The optimal management strategy remains controversial. Methods: Between 2016 and 2020, 10 patients (6 females; mean age, 49.1 years) presented to our institution with PAT in the thoracic aorta. All 10 patients were active tobacco users, and 6 patients were found to have an underlying hypercoagulable state. Locations of the PAT included the ascending aorta in 4 patients, the descending thoracic aorta in 3 patients, and the aortic root, aortic arch, and thoracoabdominal aorta in 1 patient each. At presentation, 2 patients had developed myocardial infarction, and 2 others had cerebral infarction. All patients but 1, who was managed medically for PAT, underwent open surgical thrombectomy via either sternotomy or left thoracotomy. Concomitant procedures included coronary artery bypass grafting in 2 patients and pulmonary thromboembolectomy in 1 patient. There were no operative deaths. During a median follow-up of 18 months, 2 patients developed recurrent PAT, owing primarily to poor compliance with anticoagulation. One patient required redo open thrombectomy. Two patients had mesenteric ischemia necessitating small bowel resection. Conclusions: Open surgical thrombectomy of the thoracic aorta can be performed with low mortality and morbidity; however, PAT can recur, especially in patients who have difficulty managing anticoagulation.

In vivo exclusion of giant aortic thrombus: Transesophageal echocardiography in thoracic endovascular aortic repair: A case report: Transesophageal echocardiography in thoracic endovascular aortic repair: A case report.

We present the case of a 53-year-old patient with a giant floating thrombus in the aortic arch associated with proximal stenosis of the left subclavian artery diagnosed by multimodal imaging. Left carotid-subclavian shunt and thoracic endovascular aortic repair (TEVAR) were successful. Transesophageal echocardiography (TEE) played a substantial role in the safety and efficacy of the endovascular procedure and should be considered as an additional guide to fluoroscopy for this type of procedure.

A Case of COVID-19 Induced Descending Aortic Thrombus and Splenic Infarctions.

Thromboembolic manifestations like pulmonary embolism and deep venous thrombosis are often reported and contribute to a significant mortality from acute and chronic COVID-19 infections. These phenomena are a result of the activation of the coagulation cascade by the COVID-19 induced inflammatory state. Majority of the thrombotic incidences are reported as a venous thrombosis but extremely rarely, arterial thrombi can be a manifestation of acute COVID-19 infection. The patient in our case report was an unvaccinated 47-year-old female who presented with fever, nausea, abdominal pain and vomiting. The imaging confirmed the presence of a non-occlusive thrombus in the descending aorta, multiple splenic infarctions and paralytic ileus. She was treated with systemic anti-coagulation. A hyper-coagulable workup was performed on the patient and no other risk factors that could contribute to a thrombus was identified.

Physician-modified aortic cuff to "stabilize" paravisceral aortic thrombus and minimize risk of distal embolization during pararenal aneurysm repair with fenestrated stent graft.

As technology and surgeon experience evolve, endovascular repair of complex abdominal aortic aneurysms is often preferred in appropriately selected patients. However, the presence of pedunculated aortic thrombus represents a relative contraindication for endoluminal therapy due embolization risks. Here, we present a 68-year-old woman with a 5.8-cm pararenal aortic aneurysm associated with pedunculated aortic thrombus. She was treated with a modified Cook-Zenith aortic cuff to first entrap the aortic thrombus, followed by treatment of the aneurysm with a modified Z-FEN graft. This cuff modification provides a novel approach to deal with such luminal thrombus.

Management Strategies for Descending Thoracic Aortic Thrombus: A Review of the Literature.

Descending thoracic aortic thrombus (DTAT) is an under-recognized source of systemic emboli with potential catastrophic consequences. Imaging modalities such as echocardiography, computed tomography, magnetic resonance imaging, and angiography can help identify and characterize the extent of embolic events. Established guidelines regarding the management of DTAT are currently lacking. Multiple treatment modalities are available; however, the effectiveness of each approach remains to be determined. In this study, we performed a review to examine the clinical presentation, diagnostic methods and findings, and outcomes of various treatment options for patients with DTAT. Medical management is the least invasive and most frequently chosen initial approach, offering a high reported success rate, whereas endovascular therapy can have a role in thrombus exclusion should conservative management fail.

The importance of transesophageal echocardiography evaluation in a patient with acute limb ischaemia.

This a case of a patient with acute limb ischaemia in whom thorough transesophageal echocardiography (TEE) evaluation depicted a patent foramen ovale and allowed for the detection of a large thrombus arising from an atherosclerotic calcified plaque in the thoracic aorta. We aim to illustrate the importance of performing TEE when systemic emboli are suspected and to not neglect thoracic aorta evaluation when a potential intracardiac cause has been detected.

Management of acute aortoiliac arterial thrombosis in patients with the novel coronavirus disease 2019: A case series and systematic review of the literature.

Objectives: Venous thrombosis has been widely described in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; however, arterial thrombosis has rarely been reported. This study aims to assess the incidence, risk factors, interventions, and outcomes of acute aortoiliac arterial thrombosis in patients with active SARS-CoV-2 infections. Methods: We present seven SARS-CoV-2-positive patients from our institution who acutely developed thrombi in the aortoiliac arterial system (7/2020-1/2021). A systematic review of the literature on aortoiliac arterial thrombosis in patients with SARS-CoV-2 infections in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was also performed. The available data from all reported cases in the literature and at our institution were analyzed. Results: Thirty published articles and journal correspondences, including 52 patients, were reviewed and analyzed in addition to our institution's 7 cases. In total, 59 SARS-CoV-2-positive patients were found to have acute aortoiliac thrombosis. The abdominal aorta was the most frequent location for the development of a thrombus. Baseline demographics and medical comorbidities were not significantly different between the symptomatic and asymptomatic cohorts. Seventy-one percent of patients were symptomatic (lower limb ischemia: 75.0%, renal infarction: 20.0%, stroke: 12.5%, mesenteric ischemia: 10.0%). All patients with thrombus involving the ascending aorta, aortic bifurcation, or iliac artery developed thromboembolic or ischemic complications. All patients received systemic anticoagulation. Fifty-three percent of all patients were managed medically. Ninety-four percent of the asymptomatic patients were managed medically. One asymptomatic patient underwent endovascular aspiration of a mobile thrombus. Three (23.1%) deaths occurred in the asymptomatic cohort from hypoxic respiratory failure. Fourteen (36.8%) deaths occurred in the symptomatic cohort. The in-hospital mortality rate was 33.3% overall and 43.8% for patients with thrombi involving more than one aortoiliac segment. Conclusions: The presence of thrombi in the aortoiliac arterial system appears to be a poor prognostic indicator for patients with active SARS-CoV-2 infections. Medical management of patients with asymptomatic aortoiliac thrombi may be considered. The presence of thrombi involving the ascending aorta, aortic bifurcation, or iliac artery may warrant consideration for operative intervention due to the risk for thromboembolic or ischemic complications. Further study is needed to fully delineate the risk factors, optimal treatment, and outcomes of arterial thrombosis in the setting of SARS-CoV-2 infection.

Where is the Thrombus ? Mural Ascending Aortic Thrombus with Embolic Events in a Patient with Recent COVID 19 Infection.

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has triggered a global health pandemic that led to substantial morbidity and mortality worldwide. The virus has been known to predominantly cause severe hypoxemic respiratory failure but there have been multiple reports of extra-pulmonary manifestations. Additionally, there has been increasing evidence of COVID-19 hyper-coagulability. Herein, we present a case of a 49-year-old male with a past medical history of diet controlled type II diabetes mellitus and recently diagnosed COVID-19 who presented to the emergency department with a chief complaint of nausea and vomiting. Our patient was found to have a thrombus-like appearing 1.9 cm × 1.2 cm well-circumscribed mass, attached to the greater curvature of the ascending aorta, superior to the right coronary cusp of the aortic valve almost three weeks after his initial diagnosis of COVID-19 virus.

COVID-19 and Aortic Thrombosis: A Case Report.

Coronavirus disease 2019 (COVID-19) is an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is known to cause a myriad of symptoms ranging from mild respiratory illness to severe pneumonia and acute respiratory distress. Since its discovery in late 2019 in Wuhan, China, the virus has caused a devastating worldwide pandemic. Although COVID-19 most commonly causes respiratory symptoms, complications such as hypercoagulability are now known to occur in some patients. In this case report, we present a COVID-19 patient that suffered a stroke and was found to have an aortic thrombus. In this case report, we discussed hypercoagulability, venous and arterial thrombosis in COVID-19 patients. We hope to highlight the importance of monitoring laboratory markers of hypercoagulability and thromboembolism symptoms in COVID-19 patients and encourage appropriate prophylaxis and treatment with anticoagulants when necessary. It is unclear whether or not a causal relationship exists given the nature of the syndrome. However, given the growing number of reported cases physicians should maintain awareness of this possible complication when evaluating COVID-19 patients.

Fluttering cord-like thrombus in the aortic arch.

BACKGROUND: The optimal treatment for aortic thrombus remains to be determined, but surgical treatment is indicated when there is a risk for thromboembolism. CASE PRESENTATION: A 47-year-old male presented with weakness in his left arm upon awakening. Contrast-enhanced computed tomography and transesophageal echocardiography revealed a mobile pedunculated object suggestive of a thrombus arising from the ascending aorta and extending to the left common carotid artery. It was removed under hypothermic circulatory arrest and direct cannulation of the left carotid artery to avoid carotid thromboembolism. Histopathological examination revealed that the object was a thrombus. The patient had an uneventful postoperative course and was discharged 9 days after surgery. CONCLUSION: When a thrombus in the aortic arch extends to the neck arteries, direct cannulation of the neck arteries with selective cerebral perfusion via cervical incision is a useful technique.