ATHEROSCLEROTIC THORACIC AORTA--AN UNUSUAL

SOURCE OF ARTERIAL EMBOLISM.

Dr suman Sagar GL ,Dr Sunil karanth Dr Venkatesh Gupta,Dr
Raghavendra Gouder sagar10gls@gmail.com Manipal Hospitals
Bangalore

Introduction:A mural thrombus in the thoracic aorta is a very rare cause of

systemic embolism and often goes undiagnosed.
The optimal management for this condition remains controversial.
This patient had a multiple mural aortic thrombus in the non-atherosclerotic
aorta, with mesenteric ischemia which was treated with anticoagulant.

Case presentation
A 65 years old Indian woman , with background hypertension non compliant
with medcations came to manipal hospital -ER with complaints of pain
abdomen and vomiting 2 to 3 episodes since 1 day . She was initially
admitted in an outside hospital with accelerated hypertension where NCCT
brain was done which showed old infarcts and small vessel disease. CT
aortogram showed descending thoracic aorta mass with suspicion of small
bowel ischemia.
Physical examination was remarkable for tachycardia, hypertension and
mild abdominal tenderness. Investigations ECG and cardiac
monitoring showed normal sinus rhythm. No evidence of general
cardiac pathology or valvular heart disease was evident, and the
foramen ovale was not patent.hematocrit and ,coagulation
study,thrombophilia screen was normal .
In view of accelerated hypertension (220/110 mm Hg) and metabolic
acidosis (base exess - 5 )and high lactates (5.5), CT angiography of
aorta and CECT abdomen and pelvis was done. She was transferred
to MICU for further management. In MICU, she was treated
conservatively with labetalol and heparin infusion .
CTA :Aorta shows free floating thrombus in the descending thoracic
aorta at the level of D9 and D10. Complete thrombus distal
SMA.Partial thrombosis SMV and its branches. Hypoenhancing distal
jejunal and ileal loops -likely to represent bowel ischaemia.
TEE revealed three echo-dense masses , two in descending aorta and
one in ascending aorta directly attached to the aorta (thrombus OR
angiosarcoma). No evidence of underlying acute aortic syndrome was
present.
TREATMENT FOLLOWUP :Surgical Gastroenterology and Vascular
surgery ,cardiology opinion sought and she underwent exploratory
laparotomy and small bowel resection anastomosis in view of
mesenteric ischemia. Post operatively, she was closely monitored and
was given intravenous heparin and later transitioned to low molecular
weight heparin with a target international normalised ratio (INR) of
2–3.Definitive aortic surgery was deffered in view of high operative
risk and also good establishment of collateral circulation.She was
transferred to ward with long-term anticoagulation and a follow-up
plan to monitor for resolution of thrombosis.Definitive surgery at later
 DISCUSSION
• Like the knowledge of pathophysiology, treatment regimes
are also contentious. Current opinion varies between long-
term anticoagulation, surgery, or a combination of both and
is often reliant on patient characteristics [2].
• A meta-analysis by Fayad et al. noted that up to 25% of
patients initially treated with anticoagulation would go-on to
require aortic surgery following recurrent peripheral arterial
emboli or persistent aortic mural thrombosis(AMT)[2].
• It was reported that these patients were also more likely to
suffer from recurrent distal arterial emboli, persistent AMT
and higher rates of limb amputation as a result of these
complications [2]. For these reasons, it was suggested that
patients at a higher risk of recurrence be treated with aortic
surgery as an aggressive first-line treatment option.
 REFERENCES

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