A 50-year-old woman emergently presented with severe pain of the lower extremities, cold feet, and paresthesia of the toes. Her medical history included inflammatory bowel disease (ulcerative colitis). Clinical examination revealed no femoral, popliteal, or pedal pulses. Duplex ultrasonography revealed no flow in the iliac, femoral, or distal arteries. Bilateral femoral embolectomy was performed, and fresh clots were removed. Transesophageal echocardiography (TEE) showed an echogenic image, 1.8 × 1.7 cm in transverse diameter, with aspects of embolism and with an appendage extending into the descending thoracic aorta (Fig. 1). Chest computed tomography (CT) disclosed a 1.8 × 5.6-cm embolus at the descending aorta, originating near the ostium of the left subclavian artery (Fig. 2). The patient underwent implantation of a Zenith® 28 × 140-mm stent-graft (Cook Medical Inc.; Bloomington, Ind) (Fig. 3). Thirty days later, CT showed proper positioning of the stent-graft and complete exclusion of the thrombus (Fig. 4).
Fig. 1 Transesophageal echocardiogram shows a large, mobile thrombus in the thoracic aorta.
Fig. 2 Computed tomogram with contrast shows a sub-occlusive thrombus in a transverse section of the descending aorta.
Fig. 3 Aortograms show A) the pigtail catheter guidewire and B) the released stent-graft with complete exclusion of the thrombus.
Motion images are available at www.texasheart.org/journal.
Fig. 4 Postoperative computed tomogram shows good positioning of the stent-graft and complete exclusion of the thrombus.
Comment
Mobile thrombus of the thoracic aorta is a rare entity. The routine use of TEE after embolic events has led to increased detection.1 Placing the ultrasonographic sensor in immediate contact with the aorta enables detailed examination of nearly the entire thoracic aorta, as well as the intimal surfaces. Although CT can also yield good images, the reported sensitivity is lower than that of TEE. Magnetic resonance images are useful in the diagnosis of thoracic aortic mobile thrombi, but circulatory turbulence can generate false-positive images.1
Patients with inflammatory bowel disease are 3 times more likely to experience thromboembolic complications than are individuals without the disease. Therapy should focus on preventing the evolution of mobile lesions and providing protection against their embolic potential.2 Thrombus exclusion by use of endovascular stent-grafts is a newer option among various approaches in use.2,3 In addition to excluding the thrombus, endovascular stent-grafting treats the underlying cause by covering the atherosclerotic aortic wall. Another benefit of this treatment method is the possibility of combining the thoracic procedure with peripheral embolectomy through the same surgical access site.
Supplementary Material
Footnotes
Address for reprints: Vanessa Devens Trindade, MS, 1039 São Joaquim St., Apt. 601, São Leopoldo, RS 93010-190, Brazil
E-mail: vanessad.gmail.com
References
- 1.Choukroun EM, Labrousse LM, Madonna FP, Deville C. Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 cases. Ann Vasc Surg 2002; 16(6):714–22. [DOI] [PubMed]
- 2.Piffaretti G, Tozzi M, Caronno R, Castelli P. Endovascular treatment for mobile thrombus of the thoracic aorta. Eur J Cardiothorac Surg 2007;32(4):664–6. [DOI] [PubMed]
- 3.Fueglistaler P, Wolff T, Guerke L, Stierli P, Eugster T. Endovascular stent graft for symptomatic mobile thrombus of the thoracic aorta. J Vasc Surg 2005;42(4):781–3. [DOI] [PubMed]
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