Descending Aortic Thrombus Hanging by a Thread: Three-Dimensional Echocardiogram

J INVASIVE CARDIOL 2021;33(2):E139-E140. doi:10.25270/jic/20.00114

Key words: acute limb ischemia, aortic mass

A 57-year-old woman was suspected of having embolic acute limb ischemia. An emergent angiogram showed flush occlusion of the right common femoral artery (Figure 1A). Surgical embolectomy was performed successfully, and pathology confirmed that the evacuated specimen was a blood coagulum. An exhaustive work-up for the embolic source was unrevealing until a transesophageal echocardiogram was obtained that showed a large, mobile mass (1.9 x 0.8 cm) in the descending thoracic aorta (Figure 1B; Videos 1 and 2) attached to the aortic wall by a thin peduncle (Figure 1C). Computed tomography showed multiple filling defects in the proximal descending thoracic aorta (Figures 1D-1G), with the largest measuring 1.2 x 1.4 x 1.2 cm. A complete hypercoagulable panel and age-appropriate cancer screening were both negative. The etiology of the mass was unclear; however, given the thromboembolic event, she underwent a successful, uncomplicated endovascular exclusion of the pedunculated thrombus using a 3.1 x 10 cm Tag stent (Gore) (Figure 1H). She was discharged on warfarin with a goal international normalized ratio of 2-3.

Aortic thrombus is a rarely identified source of distal embolization. A conservative approach with anticoagulation alone carries a significant risk of embolization. Various open surgical approaches have been suggested as therapeutic options, but all of them carry a significant morbidity and mortality risk in this population subgroup. Contemporary endovascular approaches aimed at exclusion of the floating thrombus are now increasingly performed, and have significantly lower periprocedural complications compared with an open surgical approach.

From ¹Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin; and ²Marcus Family Fund for Echocardiography (ECHO) Research and Education, Milwaukee, Wisconsin.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 31, 2020.

Address for correspondence: M. Fuad Jan, MD, MBBS (Hons), Aurora Cardiovascular and Thoracic Services, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI 53215. Email: publishing18@aurora.org