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Primary aortic mural thrombus: presentation and treatment
T L Hahn1, M C Dalsing, A P Sawchuk
1Department of Surgery, Peripheral Vascular Surgery Section, Indiana University School of Medicine, Indianapolis, IN.
Insights
Primary aortic thrombus can cause acute limb ischemia. Prompt treatment with embolectomy and anticoagulation can save limbs and resolve thrombus, but long-term anticoagulation may be needed.
Area of Science:
- Vascular Surgery
- Cardiology
- Internal Medicine
Background:
- Acute lower-limb ischemia can be caused by primary aortic thrombus.
- Atherosclerosis is a common cause of aortic thrombus, but primary thrombus formation without atherosclerosis is less understood.
Observation:
- A review of six patients with primary aortic thrombus causing acute lower-limb ischemia was conducted.
- Patients presented with acute lower-limb emboli requiring surgical embolectomy.
- Aortic thrombi were identified via angiography, CT, or MRI, often without associated atherosclerotic disease.
Findings:
- Surgical embolectomy followed by systemic anticoagulation led to limb salvage and thrombus resolution in all cases.
- Recurrent embolic events occurred in one patient due to warfarin cessation.
- Resolution of the underlying cause of thrombus formation was associated with successful long-term outcomes.
Implications:
- Primary aortic thrombus is a treatable cause of acute limb ischemia.
- Prompt surgical intervention and anticoagulation are crucial for limb salvage.
- Understanding the etiology of primary aortic thrombus is essential for guiding long-term management and preventing recurrence.
Abstract:
The clinical presentation of patients with acute lower-limb ischemia and primary aortic thrombus prompted this review. Following recognition of the first case in early 1994, relevant patients (n = 6) were kept in a database and were reviewed for presentation, treatment, and follow-up. The median age was 41 and five patients were male. Angiography, computed tomography, and/or magnetic resonance angiography demonstrated one or more aortic sessile or pedunculated thrombus(i) without associated atherosclerotic disease. In two cases, a retropancreatic intraaortic mural thrombus was associated with severe pancreatitis. All other cases presented with acute lower-limb emboli requiring limb salvage embolectomy. Because of significant patient illness, systemic anticoagulation was chosen acutely to prevent recurrent emboli. Interestingly, serial studies demonstrated aortic thrombus resolution. Failure to continue warfarin therapy resulted in recurrent problems (n = 1) unless the instigating event had resolved (n = 3). There were no deaths or amputations. We concluded that surgical embolectomy, when required, with subsequent anticoagulation, results in limb salvage and allows for eventual resolution of the primary aortic thrombus. Long-term anticoagulation is required unless the etiologic process resolves. The literature describes patients with atherosclerosis and overlying thrombus but fails to describe the approach to patients with primary thrombus formation.