Aortic mural thrombus presenting as pseudovasculitis

Pseudovasculitis: mechanisms of vascular injury and clinical spectrum

Pseudovasculitis, vasculitis-like syndromes, or mimics of vasculitis represent a heterogeneous collection of disorders that are capable of simulating a vasculitic disorder. Some conditions such as cardiac myxomas, cholesterol embolization, and fibromuscular dysplasia are more apt to cause confusion, but numerous other conditions can do so also. Inappropriate diagnosis leads to delay or absence of proper management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. The diagnosis of a pseudovasculitic disorder requires a high index of suspicion and should always be part of the differential diagnosis of vasculitis. The endothelium is thought to be pivotal in vascular injury; much has been learned using in vitro human umbilical vein endothelial cell cultures. Application of this knowledge to human disease and to vasculitic disorders and their imitators is still premature.

Recurrent embolism caused by floating thrombus in the thoracic aorta

A case of embolic recurrent episodes resulting in acute lower-limb ischemia from an unusual source is reported. This occurred in a patient on steroids for rheumatoid arthritis. Femoropopliteal thromboembolectomy successfully restored arterial flow. Diagnostic evaluation for identifying the source of embolism revealed a large, pedunculated and mobile thrombus arising from a nonaneurysmatic and nonatherosclerotic descending thoracic aorta. The thrombus was identified by transesophageal echocardiography and was successfully removed by aortic thromboendarterectomy. We emphasize the importance of transesophageal echocardiography as a reliable method for the diagnosis of thoracic aorta diseases and for identification of aortic thrombi. An aggressive surgical approach is recommended in the low-risk patient to prevent further embolic episodes.

Splenic infarction caused by a large thoracic aortic thrombus

We report on a patient with left upper quadrant pain as a result of splenic infarction; the patient was subsequently found to have a thoracoabdominal aortic thrombus extending through the celiac axis. The patient was successfully treated with an aortic thrombectomy guided by intraoperative transesophageal echocardiography.