Delayed Embolic Stroke From Thrombus Around Microaxial Flow Pump Insertion Site in Ascending Aorta

Direct aortic Impella 5.5 implantation has been increasingly used for high-risk cardiac surgery. Delayed complications from thrombus around the retained graft in the ascending aorta (AA) following device explantation is rarely reported.

A 55-year-old man with a history of coronary artery bypass grafting requiring Impella 5.5 via a Dacron graft on the AA developed acute thromboembolic stroke 3 years after coronary artery bypass grafting. Computed tomography angiography demonstrated a right middle cerebral artery occlusion and thrombus within the AA around the retained Impella graft. Successful middle cerebral artery mechanical thrombectomy was performed, and the intra-aortic thrombus was managed medically with oral anticoagulation, resulting in complete resolution on 1-month follow-up imaging.

This case highlights an under-recognized source of delayed embolic stroke for which no surveillance or anticoagulation guidelines currently exist.

Intra-aortic thrombus around the graft should be considered in patients presenting with delayed stroke after direct aortic Impella 5.5 explantation.