J Korean Surg Soc.  2011 Mar;80(3):204-211. 10.4174/jkss.2011.80.3.204.

Free Floating Thrombus of the Aorta: An Unusual Cause of Peripheral Embolization

• Kim SD
• Hwang JK
• Lee JH
• Cho HJ
• Sung GY
• Moon IS
• Kim JI

• KMID: 1963584
• DOI: http://doi.org/10.4174/jkss.2011.80.3.204

Abstract

PURPOSE
Free-floating thrombus (FFT) of the aorta is very rare but has a high risk of distal embolization. While the necessity of treating such a condition is evident, the diagnostic and therapeutic modalities remain controversial. Thus, we reviewed seven cases of FFT of the aorta.
METHODS
A retrospective study was performed usings even patients diagnosed with FFT of the aorta at the Catholic University of Korea between January 1999 and December 2008. We excluded those patients who had thrombi with concomitant atherosclerotic or aneurysmal aorta.
RESULTS
The mean patient age was 59.6+/-13.6 years old. The male-to-female ratio was 3:4. Embolization to arteries of the extremities occurred in two patients and to visceral arteries in four patients. Of these seven patients, four were initially treated with anticoagulation, and two were initially treated with thrombectomy; one patient refused any kind of treatment. Of the four patients treated with anticoagulation, three experienced complete dissolution of the thrombi while anticoagulation proved ineffective in the remaining patient who subsequently underwent thrombectomy. In all of the three patients who had received thrombectomy, postoperative anticoagulation was employed. There was no recurrence of FFT of the aorta during the follow-up period.
CONCLUSION
Were commend systemic anticoagulation with low molecular weight heparin (LMWH) as the first line of treatment for FFT of the aorta. If the thrombus persists or recurrent embolism occurs during anticoagulation therapy, surgery should be undertaken.

Keyword

Free-floating thrombus; Aorta; Embolization

MeSH Terms

Aneurysm
Aorta*
Arteries
Embolism
Extremities
Follow-Up Studies
Heparin, Low-Molecular-Weight
Humans
Korea
Recurrence
Retrospective Studies
Thrombectomy
Thrombosis*
Heparin, Low-Molecular-Weight

Figure

• 

  Fig. 1 CTA shows the complete dissociation of thrombus by anticoagulation therapy for the floating thrombus of the aorta.The A shows the CTA finding before anticoagulation therapy. The arrow indicates the floating thrombus of the descending thoracic aorta, and the arrow head indicates the splenic infarction. The B shows the CTA finding after anticoagulation for two weeks. The arrow indicates the complete dissociation of the floating thrombus of the descending thoracic aorta, and the arrow head indicates the healing of the splenic infarction. The C shows the CTA findings three months after initial anticoagulation was started. The arrow and the arrow head indicate that there is no reccurrence of the floating thrombus and the splenic infarction.

• 

  Fig. 2 CTA and operative findings show the case that thrombectomy and splenectomy have been done since anticoagulation was ineffective for the floating thrombus of the abdominal aorta and the splenic infarction. The A shows the CTA finding before treatment. The empty arrow indicates the floating thrombus of the abdominal aorta, and the arrow head indicates the splenic infarction. The B shows the intraoperative finding. The arrow indicates the floating thrombus arising from the lumbar artery. There is no atherosclerotic and aneurysmal change in the aorta. The C shows the removed thrombus. The length measures nearly 3.5 centimeter (cm). The D shows the CTA finding after thrombectomy and splenectomy. The empty arrow indicates that the floating thrombus of the abdominal aorta has been completely removed. The arrow head indicates that the splenectomy has been done.

Reference

1. Rancic Z, Pfammatter T, Lachat M, Frauenfelder T, Veith FJ, Mayer D. Floating aortic arch thrombus involving the supraaortic trunks: successful treatment with supra-aortic debranching and antegradeendograft implantation. J Vasc Surg. 2009. 50:1177–1180.

2. Choukroun EM, Labrousse LM, Madonna FP, Deville C. Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 cases. Ann Vasc Surg. 2002. 16:714–722.

3. Berneder S, Van Ingen G, Eigel P. Arch thrombus formation in an apparently normal aorta as a source for recurrent peripheral embolization. Thorac Cardiovasc Surg. 2006. 54:548–549.

4. Onwuanyi A, Sachdeva R, Hamirani K, Islam M, Parris R. Mutiple aortic thrombi associated with protein C and S deficiency. Mayo Clin Proc. 2001. 76:319–322.

5. Shapiro ME, Rodvien R, Bauer KA, Salzman EW. Acute aortic thrombosis in antithrombin III deficiency. JAMA. 1981. 245:1759–1761.

6. Josephson GD, Tiefenbrun J, Harvey J. Thrombosis of the descending thoracic aorta: a case report. Surgery. 1993. 114:598–600.

7. Hanson JA, Lloyd ME, Hughes GR. Aortic root thrombus causing stroke in a patient with systemic lupus erythematosus. Scand J Rheumatol. 1994. 23:156–158.

8. Geha AS, El-Zein C, Massad MG, Bagai J, Khoury F, Evans A, et al. Surgery for aortic arch thrombosis. Thorac Cardiovasc Surg. 2004. 52:187–190.

9. Agolini SF, Shah KT, Goodreau JJ, McLoughlin TM Jr, Sinclair MC. Splenic infarction caused by a large thoracic aortic thrombus. J Vasc Surg. 1997. 26:1069–1072.

10. Kalangos A, Baldovinos A, Vuille C, Montessuit M, Faidutti B. Floating thrombus in the ascending aorta: a rare cause of peripheral emboli. J Vasc Surg. 1997. 26:150–154.

11. Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromsoses of the aortic arch without aortic debris: a transesophageal echocardiographic finding associated with unexplained arterial embolism. Circulation. 1997. 96:288–294.

12. Karalis DG, Chandrasekaran K, Victor MF, Ross JJ Jr, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol. 1991. 17:73–78.

13. Piffaretti G, Tozzi M, Mariscalco G, Bacuzzi A, Lomazzi C, Rivolta N, et al. Mobile thrombus of the thoracic aorta: management and treatment review. Vasc Endovascular Surg. 2008. 42:405–411.

14. Choukroun EM, Labrousse LM, Madonna FP, Deville C. Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 cases. Ann Vasc Surg. 2002. 16:714–722.

15. Fanelli F, Gazzetti M, Boatta E, Ruggiero M, Lucatelli P, Speziale F. Acute left arm ischemia associated with floating thrombus in the proximal descending aorta: combined endovascular and surgical therapy. Cardiovasc Intervent Radiol. 2010. Epub ahead.

16. Pousios D, Velissaris T, Duggan S, Tsang G. Floating intraaortic thrombus presenting as distal arterial embolism. Interact Cardiovasc Thorac Surg. 2009. 9:532–534.

17. Madershahian N, Kuhn-Regnier F, Mime LB, Slottosch I, Langebartels G, Sindhu D, et al. A loose cannon: free-floating thrombus in ascending aorta. J Card Surg. 2009. 24:198–199.

18. Ryu YG, Chung CH, Choo SJ, Kim YS, Song JK. A case of antiphospholipid syndrome presenting with a floating thrombus in the ascending aorta. J Thorac Cardiovasc Surg. 2009. 137:500–502.

19. Sari I, Davutoglu V, Bayram N, Soydinc S. Fatal giant aortic thrombus presenting with pulmonary edema in a patient with chronic obstructive pulmonary disease. Clin Appl Thromb Hemost. 2008. 14:486–488.

20. Criado E, Wall P, Lucas P, Gasparis A, Proffit T, Ricotta J. Transesophageal echo-guided endovascular exclusion of thoracic aortic mobile thrombi. J Vasc Surg. 2004. 39:238–242.

21. Soleimani A, Marzban M, Sahebjam M, Shirani S, Sotoudeh-Anvari M, Abbasi A. Floating thrombus in the aortic arch as an origin of simultaneous peripheral emboli. J Card Surg. 2008. 23:762–764.

22. Sanon S, Phung MK, Lentz R, Buja LM, Tung PP, McPherson DD, et al. Floating, non-occlusive, mobile aortic thrombus and splenic infarction associated with protein C deficiency. J Am Soc Echocardiogr. 2009. 22:1419e1–e3.

23. Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002. 36:713–719.

24. Gouëffic Y, Chaillou P, Pillet JC, Duveau D, Patra P. Surgical treatment of nonaneurysmal aortic arch lesions in patients with systemic embolization. J Vasc Surg. 2002. 36:1186–1193.

25. Vorwerk D, Günther RW, Schürmann K, Schmitz-Rode T, Biesterfeld S. Percutaneous balloon embolectomy with a self-expanding tulip sheath: in vivo experiments. Radiology. 1995. 197:153–156.

26. Vorwerk D, Günther RW, Schürmann K, Schmitz-Rode T. New device for wire and catheter capturing: in vivo experiments and first clinical experience. Cardiovasc Intervent Radiol. 1995. 18:312–314.

27. Vorwerk D, Schmitz-Rode T, Schürmann K, Tacke J, Guenther RW. Use of a temporary caval filter to assist percutaneous iliocaval thrombectomy: experimental results. J Vasc Interv Radiol. 1995. 6:737–740.

28. Vorwerk D, Guenther RW, Clerc C, Schmitz-Rode T, Imbert C. Percutaneousembolectomy: in vitro investigations of the self-expanding tulip sheath. Radiology. 1992. 182:415–418.

29. Zhang WW, Abou-Zamzam AM, Hashisho M, Killeen JD, Bianchi C, Teruya TH. Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization. J Vasc Surg. 2008. 47:193–196.