Management of floating thrombus in the aortic arch

Abstract

25 26Objective: Floating aortic thrombus is an under-recognised source of systemic emboli 27 and carries a life-threatening risk of stroke when located in the aortic arch. Optimal 28 treatment is not established in available guidelines. We report our experience in 29 managing floating thrombi in the aortic arch. were identified. Eight patients presented with a symptomatic embolic event while two 37 patients were asymptomatic. One patient presenting with stroke due to embolic 38 occlusion of all supra-aortic vessels died two days following admission. Three patients 39 (two asymptomatic and one unfit for surgery) were treated conservatively by 40 anticoagulation, leading to thrombus resolution in two patients. In the third patient, the 41 thrombus persisted despite anticoagulation, resulting in recurrent embolic events. 42The remaining six patients underwent open thrombectomy of the aortic arch during 43 deep hypothermic circulatory arrest. All patients treated by surgery had an uneventful 44 postoperative course with no recurrent thrombus or embolic event during follow-up. 45Median follow-up of all patients was 17 months (range 11 -89 months). 46

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

“…226 An aortic arch thrombus bears the risk of life-threatening stroke and peripheral embolization. 227 The morphological form of the thrombus should be taken into consideration by distinguishing a mobile (i.e. floating, bulging into the lumen) from a stationary (mural lining) thrombus.…”

“…228 A recently published case series reported excellent outcome with regard to survival and freedom from recurrence of thrombus formation with surgical thrombectomy. 227 The value of minimally invasive approaches including transarterial balloon thrombectomy or catheter-based percutaneous thrombus aspiration remains unclear. Follow-up imaging is recommended in patients under conservative treatment to assess for thrombus dissolution.…”

Giant Aortic Thrombus in the Ascending Aorta and Perforation of Bowel Associated With Cocaine Use

“…In many clinical reports and series, it was detected only after a distal embolic event occurred without a known cause, and most cases were amenable to surgical intervention [1,2]. In some instances, it was detected incidentally in completely asymptomatic patients [3]. We believe that complete resection of the aortic mass is indicated in symptomatic patients because of the risk of recurrence and embolic complications.…”

“…We believe that surgical intervention is favored in this case because of the presence of symptomatic embolic sequelae and the risk of fragmentation of the thrombus with prolonged anticoagulation. Clinical reports from the literature suggest that most clinicians would advocate a definitive treatment involving surgical removal of thrombus to prevent the dislodgement of emboli and total occlusion of blood flow [3]. Depending on the location of the thrombus, circulatory arrest may be required.…”

Management and clinical outcome of concomitant pulmonary embolism and paradoxical saddle aortic arch embolism

“…Aortic thrombosis can also be due to underlying atherosclerotic disease with superimposed acute thrombus or hypercoagulability states 5–7. Free floating thrombus in a diseased thoracic aorta complicated by thromboembolic episodes may be treated surgically by open thrombectomy, endovascular techniques or non-operatively with anticoagulation or thrombolysis 8–11…”