In a recent development, doctors have put forth a case report of a male patient with a floating thrombus in an otherwise healthy distal ascending aorta. The rare and interesting case report has been published in BMC Surgery.
An aortic mural thrombus (AMT) without an aneurysm or dissection is rare, with an incidence rate of about 0.45% . It is occasionally identified incidentally, either by a source of systemic emboli or by computed tomography angiography (CTA). The most common locations for AMTs are the aortic isthmus, descending thoracic aorta and lower abdominal aorta, with the rarest location being the ascending aorta . The pathogenesis and treatment strategies for AMTs are still limited to those found in case reports, and there is no consensus.
Addressing the rarity of the case, the team wrote "To the best of our knowledge, such a large floating thrombus in the ascending aorta that has not caused devastating complications has rarely been reported. The pathophysiological mechanisms of AMT remain unclear, although coagulopathy, immunological disorders, malignancies, intra-aortic atheroma, aortic structural abnormalities, trauma, steroid use, and substance abuse have all been suggested as possible causes . This was not the case for our patient, however."
The 49-year-old man presented with chest discomfort for 5 days and was admitted to our emergency unit. His medical history was unremarkable, except for cigarette smoking and a lower left limb embolic event that was treated by surgical embolectomy 3 years prior. Electrocardiography and laboratory tests were normal. A contrast-enhanced CTA surprisingly demonstrated a large filling defect suggestive of a thrombus in a healthy distal ascending aorta. Further investigations, including autoimmune, thrombophilia, and blood culture studies were negative, and so did his family.
Surgeons planned a surgical removal of the intra-luminal mass to avoid the recurrence of a peripheral or visceral embolism. After thrombus removal, an extensive area of intimal defect and an abnormally thick and fragile aortic wall was observed at the attachment site. To seal the prothrombotic area and avoid recurrence, the ascending aorta and proximal arch were replaced with a 28 mm Dacron vascular prosthesis conduit.
The postoperative course was uneventful, and the patient was discharged from the hospital 7 days after surgery. No complications were reported in 3-month follow-up. The CTA scan at the 3-month follow-up confirmed the stability of the grafts without a recurrence of an aortic thrombus.
AMTs are prone to break off, thus carrying a potential risk of cerebral, peripheral, or visceral embolic events with catastrophic consequences . The most common embolic site is the lower extremity artery, with the next most common sites being the mesenteric and renal arteries. The rarest embolic sites are the cerebral and coronary arteries, but these were often the most lethal and seriously affected the prognosis.
"For a suspected ascending aortic floating thrombus, we advocate CTA, combined with transesophageal echocardiography, for a comprehensive assessment of an AMT. Surgical resection, both of the aortic thrombus and attachment site, as well as postoperative anticoagulant administration, are standard treatments. However, elderly patients or those with an extremely high risk from surgery can choose conservative drug treatment or endovascular treatment, if necessary."concluded the team.
For full article follow the link: https://doi.org/10.1186/s12893-020-00983-6
Primary source:BMJ surgery