Successful Thrombolysis of an Aortic-Arch Thrombus in a Patient after Mesenteric Embolism

Hausmann, Dirk; Gulba, Dietrich C.; Bargheer, Klaus; Niedermeyer, J; Ka, Comess; Daniel, WG

doi:10.1056/nejm199208133270717

Cited by 112 publications

(5 citation statements)

References 8 publications

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“…Likewise, it has been described the disappearance of these mobile lesions after anticoagulation [42, 43] and thrombolysis [44]. The most remarkable common finding in all these observational or retrospective studies in patients with stroke or peripheral embolism is the high prevalence of atherosclerosis of the aortic arch (between 20% and 30%), which results of similar (or even greater) magnitude than the prevalence of carotid artery stenosis or atrial fibrillation in patients with stroke [5, 28, 45].…”

Section: Prevalence Of Aortic Arch Atheroma In Patients With Strokementioning

confidence: 99%

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Complex Atheromatosis of the Aortic Arch in Cerebral Infarction

Capmany

Ibanez²,

Pesquer³

2010

CCR

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In many stroke patients it is not possible to establish the etiology of stroke. However, in the last two decades, the use of transesophageal echocardiography in patients with stroke of uncertain etiology reveals atherosclerotic plaques in the aortic arch, which often protrude into the lumen and have mobile components in a high percentage of cases. Several autopsy series and retrospective studies of cases and controls have shown an association between aortic arch atheroma and arterial embolism, which was later confirmed by prospectively designed studies. The association with ischemic stroke was particularly strong when atheromas were located proximal to the ostium of the left subclavian artery, when the plaque was ≥ 4 mm thick and particularly when mobile components are present. In these cases, aspirin might not prevent adequately new arterial ischemic events especially stroke. Here we review the evidence of aortic arch atheroma as an independent risk factor for stroke and arterial embolism, including clinical and pathological data on atherosclerosis of the thoracic aorta as an embolic source. In addition, the impact of complex plaques (≥ 4 mm thick, or with mobile components) on increasing the risk of stroke is also reviewed. In non-randomized retrospective studies anticoagulation was superior to antiplatelet therapy in patients with stroke and aortic arch plaques with mobile components. In a retrospective case-control study, statins significantly reduced the relative risk of new vascular events. However, given the limited data available and its retrospective nature, randomized prospective studies are needed to establish the optimal secondary prevention therapeutic regimens in these high risk patients.

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Section: Prevalence Of Aortic Arch Atheroma In Patients With Strokementioning

confidence: 99%

“…It has been shown that moving components superimposed to plaques generally correspond to thrombus [35, 40-44], and that this is the greatest risk factor for recurrent embolism [37, 53]. Accordingly, it seems logical to prescribe anticoagulation to prevent further ischemic events.…”

Section: Complex Aortic Arch Treatment In Stroke Patientsmentioning

confidence: 99%

Complex Atheromatosis of the Aortic Arch in Cerebral Infarction

Capmany

Ibanez²,

Pesquer³

2010

CCR

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“…But when dealing with ascending aortic thrombus, endovascular treatment may pose the risk of dislodging the thrombus during the stent placement, giving rise to fatal embolism [ 7 ]. Thrombolysis, though infrequently performed in managing aortic thrombus, has also provided successful treatments in some cases [ 36 ]. Conventional surgery can remove the aortic thrombus once for all and avoid recurrent embolism, but as a more invasive choice, it involves sternotomy procedure, cardiopulmonary bypass, deep hypothermia and a subsequent series of post-operative complications, including arrhythmias and even post-thrombectomy mortality [ 37 ].…”

Section: Discussionmentioning

confidence: 99%

Repeated acute coronary syndrome caused by a mind-bending mural thrombus in ascending aorta: a case report and review of the literature

Liu,

Yu,

et al. 2024

BMC Cardiovasc Disord

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Background Acute coronary syndrome due to coronary artery embolism in the setting of ascending aortic thrombus is an uncommon condition, even rarer when there is no aortic pathology such as aneurysm, severe atherosclerosis, aortic dissection, or thrombophilia (whether inherited or acquired). Case presentation We report a case of a 58-year-old male presented with acute chest pain, electrocardiogram showing non-ST-elevation acute coronary syndrome. The computed tomography angiography of coronary artery revealed a mural thrombus in the proximal part of ascending aorta, located above the left coronary artery ostium, without any aortic pathologies. With the exception of hypertension and cigarette smoking, no other risk factors were identified in this patient that may increase the risk of thrombosis. Given the life-threatening risk of interventional therapy and surgery, the patient determinedly opted for anticoagulant and dual antiplatelet therapy. Then he experienced the reoccurrence of chest pain after 6-day treatment, progressed to anterior and inferior ST-segment elevation myocardial infarction. Coronary artery embolism originating from the ascending aortic thrombus was suspected. Considering the hemodynamic instability of the patient, the medical treatment was continued and bridged to warfarin and aspirin after discharge. Follow-up computed tomography angiography at 6 months showed no obstruction in coronary artery and complete resolution of the thrombus. No thromboembolic events occurred henceforward. Conclusions Acute coronary syndrome could be a manifestation of secondary coronary embolism due to ascending aortic thrombus. Currently, there is no standardized guideline for the treatment of aortic mural thrombus, individualized treatment is recommended. When surgical therapy is not applicable for the patient, anticoagulation and dual antiplatelet treatment are alternative treatments that may successfully lead to the resolution of the aortic thrombus.

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“…Studies and guideline-directed management options are currently limited, and there have not been any prospective trials addressing therapeutic strategies. Options for treatment include anticoagulation, aortic surgery, thrombolytic therapy, and thromboaspiration [1, 15, 16]. The most common approach to initial management is anticoagulation [2, 5].…”

Section: Discussionmentioning

confidence: 99%

Peripherally Embolizing Aortic Thrombus: The Work-Up, Management, and Outcome of Primary Aortic Thrombus

Mando

Gemayel

Chaddha

et al. 2019

Case Reports in Cardiology

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Background. Primary aortic thrombus is an uncommon entity and not frequently reported in the literature. Herein, we discuss the presentation and management of a patient with a primary thoracic mural thrombus. Case Summary. A 46-year-old female with past medical history of tobacco dependence presented for low-grade fever and sudden onset, severe right upper quadrant abdominal pain with associated nausea and vomiting. Computed tomography (CT) revealed an intraluminal polypoid filling defect arising from the isthmus of the aorta projecting into the proximal descending aorta and findings consistent with infarction of the spleen and right kidney. Infectious, autoimmune, hematologic, and oncologic work-up were all unyielding. The patient was started on heparin and later transitioned to apixaban 5 mg twice a day and 81 mg of aspirin daily. She was also counseled regarding smoking cessation. Two months follow-up CT revealed resolution of the thrombus. Patient had no further thromboembolic complications. Discussion. We present a unique case of primary aortic thrombus. To our knowledge, this is the first reported case managed successfully with a NOAC. This diagnosis is one of exclusion and through work-up should be completed. Our aim is to raise awareness of this condition and successful management with apixaban in low-risk patients.

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Successful Thrombolysis of an Aortic-Arch Thrombus in a Patient after Mesenteric Embolism

Cited by 112 publications

References 8 publications

Complex Atheromatosis of the Aortic Arch in Cerebral Infarction

Complex Atheromatosis of the Aortic Arch in Cerebral Infarction

Repeated acute coronary syndrome caused by a mind-bending mural thrombus in ascending aorta: a case report and review of the literature

Peripherally Embolizing Aortic Thrombus: The Work-Up, Management, and Outcome of Primary Aortic Thrombus

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