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Mural aortic thrombi: An important cause of peripheral embolization
P U Reber1, A G Patel, E Stauffer
1Division of Vascular Surgery, Inselspital, University of Bern, Switzerland.
Insights
Mural aortic thrombi (MAT) are an underrecognized cause of arterial thromboembolism. Imaging like CT or MRI is crucial for diagnosis, and surgical removal of MAT offers successful treatment with low morbidity.
Area of Science:
- Vascular Surgery
- Cardiology
- Diagnostic Imaging
Background:
- Arterial thromboembolism from unknown sources leads to significant morbidity and mortality.
- Advances in imaging, including transesophageal echocardiography (TEE), magnetic resonance imaging (MRI), and computed tomography (CT), have increased the identification of mural aortic thrombi (MAT) as an embolic source.
- MAT were previously underappreciated as a cause of distal embolization.
Purpose of the Study:
- To report the incidence, diagnosis, and treatment of patients with mural aortic thrombi (MAT).
- To highlight MAT as a significant source of arterial thromboembolism.
- To evaluate the diagnostic and therapeutic approaches for MAT.
Main Methods:
- A prospective study included 89 patients with acute embolic events from January 1996 to December 1998.
- Patients underwent extensive diagnostic workup, including TEE, CT, or MRI, to identify the source of embolization.
- Patients with cardiac sources, aortoiliac disease, or aortic aneurysms were excluded, identifying 8 patients with MAT.
Main Results:
- Mural aortic thrombi (MAT) were identified in 9% of patients with arterial thromboembolism, with a median age of 63 years.
- Percutaneous catheter aspiration embolectomy was successful in six patients; two underwent surgical thromboembolectomy, with 25% requiring below-knee amputation.
- MAT were detected in the ascending, thoracic, and abdominal aorta using TEE, CT, or MRI. Surgical removal in seven patients resulted in no intraoperative or postoperative complications, with no recurrence during follow-up.
Conclusions:
- Mural aortic thrombi (MAT) are an important and often overlooked source of arterial thromboembolism.
- Aortic imaging (CT or MRI) is recommended for patients with unexplained embolic events after other sources are ruled out.
- Surgical treatment of MAT can be effective with low mortality and morbidity, though further prospective evaluation is needed.
Purpose:
Arterial thromboembolism in patients with an unknown source of embolization is still associated with significant morbidity and mortality. The advent of transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) and the more frequent use of computed tomography (CT) have led to the identification of mural aortic thrombi (MAT) as a source of distal embolization in a much higher proportion of patients than previously appreciated. The incidence, diagnosis, and treatment of patients with MAT is reported.
Methods:
In a prospective study, from January 1996 to December 1998, 89 patients with acute embolic events underwent an extensive diagnostic workup, consisting of TEE, CT, or MRI, to detect the source of embolization. Patients in whom the heart (n = 51), occlusive aortoiliac disease (n = 16), or aortic aneurysms (n = 12) was identified as the source of embolization were excluded.
Results:
Five female and three male patients, with a median age of 63 years (range, 35 to 76 years), with bilateral or repetitive embolic events resulting from MAT were identified, representing 9% of all patients with arterial thrombembolism. All patients had several risk factors for atherosclerosis, but only one young patient had a single risk factor that promoted thrombosis. Successful percutaneous catheter aspiration embolectomy was performed in six patients. The remaining two patients underwent surgical thromboembolectomy. A below-knee amputation had to be performed in two patients, thus representing a morbidity of the primary treatment of 25%. MAT of equal value were detected in the ascending (n = 1) and thoracic aorta (n = 3) by means of TEE, CT, or MRI. MAT in the abdominal aorta (n = 4) were identified by means of CT and MRI. Surgical removal of MAT was performed in seven patients by means of graft replacement of the ascending aorta (n = 1), open thrombectomy of the descending aorta (n = 2), and thrombendarterectomy of the abdominal aorta (n = 4), without intraoperative or postoperative complications. No recurrence of MAT occurred during a median follow-up period of 13 months (range, 4 to 24 months).
Conclusion:
MAT represent an important source of arterial thrombembolism. A diagnostic workup of the aorta, preferably by means of CT or MRI, should be performed in all patients in whom other sources of embolization have been ruled out. The ideal therapeutic approach to these patients still awaits prospective evaluation. However, based on our experience, MAT can be successfully treated with a definitive surgical procedure in selected patients, with low mortality and morbidity.