Floating thrombus involving the aortic arch in a woman
Article information
A 45-year-old female patient was referred to the emergency department complaining of acute pain in the right upper limb, with preserved mobility and numbness of the last three fingers; no pulses were detectable. The patient’s history was not significant. The electrocardiogram showed a sinus rhythm. A computed tomography angiography (CTA) confirmed the occlusion of both radial and ulnar arteries and a pedunculated thrombus of the aortic arch in an otherwise healthy aorta (Fig. 1A). Symptoms resolved after emergent embolectomy (Fig. 1B, C). Continuous intravenous infusion of heparin and clopidogrel was started.
Images of the patient. (A) The computed tomography scan of the first thoracic aorta detected a floating thrombus (arrow). After emergent Fogarty embolectomy, (B) a trilobate embolus occluding the omeral bifurcation was removed, (C) with an excellent postprocedure angiographic result. (D) Magnetic resonance imaging confirmed a thrombus adherent to the aortic wall (arrow). (E) The 1-month computed tomography scan showed complete resolution of the mural thrombus after medical therapy.
The diagnosis of aortic mural thrombus (AMT), excluding concomitant atrial thrombi, was confirmed after an echocardiogram and a cardiac magnetic resonance exam (Fig. 1D). Five days later, she started a vitamin K antagonist. At 4 weeks, a new CTA showed complete resolution of the AMT (Fig. 1E), so the patient was discharged. No thrombotic risk factors were found, and acenocoumarol was stopped after 6 months.
AMT is characterized by sessile or pedunculated aortic thrombi without concomitant aneurysm or dissection. It is a rare and uncommon cause of acute limb ischemia, with an incidence rate of about 0.45% [1]. The most common locations of AMT are the aortic isthmus, descending thoracic aorta, and lower abdominal aorta [2]; other embolic sources must be rapidly excluded. Since it is a rare pathology, the best treatment strategy is unknown, with no consensus [3,4]. In our case, an early CTA reevaluation (not shown) detected a significant change in thrombus size, suggesting an optimal response to medical therapy, avoiding major surgical risks. Emergency clinicians must always be alert to young patients presenting with arterial embolisms and should consider a “zebra” diagnosis if applicable.
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Ethics statement
Informed consent for publication of the research details and clinical images was obtained from the patient.
Author contributions
Conceptualization: all authors; Investigation: GP, IDS; Visualization: IDS, MM; Writing–original article: GP, IDS, MM; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
References
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Capsule Summary
What is already known?
Aortic mural thrombus is rare but potentially life-threatening. After a challenging diagnosis, young patients are usually treated with surgery, reserving medical therapy alone for the elderly or those at high surgical risk.
What is new in the current study?
Early reevaluation after starting anticoagulant therapy is very useful. A less invasive approach can be considered initially, as in patients at high embolic risk.