Floating thrombus in the ascending aorta

Aortic Thrombus in a Nonaneurysmal Ascending Aorta

BACKGROUND

Ascending aortic thrombus (AAT) in a nonaneurysmal aorta is an extremely rare event and has potentially catastrophic complications, with a life-threatening risk of myocardial infarction and cerebral embolization. This systematic review aims to elucidate the clinical manifestations and to compare the outcomes of anticoagulation therapy versus open aortic surgery for AAT.

METHODS

The MEDLINE/PubMed databases were extensively searched between 1995 and 2019. All relevant publications on AAT in adults were reviewed, and individual patient data were pooled in this meta-analysis. The primary outcome was AAT resolution. The adverse outcome variables were recurrent arterial embolic events, complications related to open aortic surgery, and mortality during the study period. Chi-squared test and logistic regression analysis were used to compare groups and identify any predictors of mortality.

RESULTS

Overall, 107 patients from 101 articles were included, of whom 29 patients who received anticoagulation therapy and 59 who underwent open aortic surgery were included in the outcome analysis. Among 29 patients treated with initial anticoagulation therapy, the persistence of AAT was observed in 11 patients (38%) and recurrent arterial embolization was developed in 6 patients (21%). All 11 patients in the anticoagulation group underwent secondary aortic surgery for the persistence of AAT with uneventful postoperative course. Compared with patients treated with primary aortic surgery, patients treated with initial anticoagulation therapy had higher risk of recurrent embolization (P = 0.002). No significant difference existed in the mortality rates between the groups (P = 0.106). Hemodynamic instability was an independent predictor of mortality (P = 0.008).

CONCLUSIONS

Anticoagulation therapy and open aortic surgery for AAT show similar results; however, open aortic surgery reliably removes AAT and reduces the risk of recurrent embolization compared with anticoagulation therapy. Furthermore, the preoperative hemodynamic status significantly influences the clinical outcome and is a strong predictor of prognosis.

A case of thrombus of the descending aorta successfully diagnosed on preoperative endoscopic ultrasonography

A 45-year-old woman presented with left lower abdominal pain. A plain CT scan showed a slightly high-density, cord-like structure extending from the level of the diaphragm of the descending aorta to the superior mesenteric artery. Transgastric endoscopic ultrasonography (EUS) revealed a floating mass, smoothly attaching to the aortic intima and depicted as a hyperechoic region containing a mixture of hyperechoic and hypoechoic areas. EUS elastography revealed that the body of the mass consisted of medium soft tissue, with hard tissue at its base. On histopathological examination after surgery, the mass was found to consist mainly of fibrin, with no atypical cells. EUS examination should be used for the differential diagnosis between thrombi and tumors in the aorta.

Exophytic Atheroma Mimicking Papillary Fibroelastoma Adjacent to the Aortic Valve

Follow-up echocardiography in a 69-year-old man with alcoholic cardiomyopathy showed a mass above the aortic valve near the left coronary ostium. Transesophageal echocardiography and computed tomography suggested a papillary fibroelastoma with a high risk of embolism. At operation we found an exophytic atheroma adjacent to the left coronary artery orifice. The atheroma was removed, and the patient made an uneventful recovery. We describe this very rare case of an exophytic atheroma mimicking a papillary fibroelastoma situated at the left coronary orifice.

Giant thrombus in the ascending aorta that caused systemic embolism

Although an ascending aortic thrombus is a rare finding, it may cause major embolic complications. We report a case of a 58-year-old male who suffered from cerebral and left renal infarctions due to emboli from a giant thrombus in the ascending aorta. The thrombus was demonstrated by computed tomography and transesophageal echocardiography. Ten days after the initiation of anticoagulation therapy, surgery was performed. After a median sternotomy was performed and cardiopulmonary bypass was initiated, the ascending aorta was replaced with a synthetic graft under hypothermic circulatory arrest and retrograde cerebral perfusion. The excised specimen revealed a 3.5×3.0×3.0-cm pedunculated thrombus. The patient's postoperative recovery was uneventful, and there was no recurrence of aortic thrombosis during one year of postoperative follow-up. The patient had no coagulation disorders, and the etiology of this giant thrombus remains unclear. We believe that initial treatment for an ascending aortic thrombus should be emergency surgery before it leads to major embolic events. However, the treatment strategy for a thrombus causing cerebral infarction is sometimes difficult to develop.