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Mobile Menace: Floating Aortic Arch Thrombus

  • Ami Schattner
    Correspondence
    Requests for reprints should be addressed to Ami Schattner, MD, Department of Medicine, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
    Affiliations
    Department of Medicine, Kaplan Medical Center, Rehovot, Israel

    Hebrew University and Hadassah Medical School, Jerusalem, Israel
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  • Meital Adi
    Affiliations
    Hebrew University and Hadassah Medical School, Jerusalem, Israel

    Department of Radiology, Kaplan Medical Center, Rehovot, Israel
    Search for articles by this author
      To the Editor:
      A healthy, nonsmoking 72-year-old man presented with a history of a change in bowel habits followed by rectal bleeding. Colonoscopy demonstrated a rectosigmoid cancer. A preoperative staging computed tomography scan revealed a large (1.2 cm) intraluminal free (unconnected to the wall) filling defect in the proximal descending aorta (Figure A) and some ipsilateral pleural effusion. Multiple splenic infarcts, which were asymptomatic, were seen (Figure B). Transesophageal echocardiography confirmed the presence of a mobile mass, but the cardiac cavities, valves, and aortic wall were normal. No cause of arterial hypercoagulability other than the tumor was found. Thoracotomy was performed and a fragile thrombus was successfully removed. One month later, low-molecular-weight heparin was temporarily discontinued and a large penetrating rectosigmoid adenocarcinoma was removed (T4a N1 M0). Chemotherapy was started and the patient had an uneventful course for 3 years until liver metastases were discovered.
      Figure thumbnail gr1
      FigureAxial and coronal contrast enhanced computed tomography scan showing (A) a floating thrombus in the proximal descending aorta (white arrow) and (B) a hypodense splenic lesion consistent with infarction (black arrow). No atherosclerotic changes are seen in the aorta.
      Isolated mobile thrombus of the thoracic aorta without an aneurysm or dissection is a rare condition, but should be sought in patients with unexplained cerebral or peripheral embolism.
      • Laperche T.
      • Laurian C.
      • Roudaut R.
      • Steg P.G.
      Mobile thromboses of the aortic arch without aortic debris: a transesophageal echocardiographic finding associated with unexplained arterial embolism.
      Although most of the thromboembolic phenomena associated with cancer are venous events, arterial thromboembolism can occur. Its occurrence in patients with diverse solid tumors is well documented,
      • Sanon S.
      • Lenihan D.J.
      • Mouhayar E.
      Peripheral arterial ischemic events in cancer patients.
      and multiple mechanisms may be involved, including the hypercoagulability of malignancy,
      • Falanga A.
      • Marchetti M.
      • Vignoli A.
      Coagulation and cancer: biological and clinical aspects.
      arterial compression by the tumor, and adverse effects of chemotherapy. In our patient, mobile floating thrombus in the aortic arch and splenic emboli had been incidentally discovered concurrent with the diagnosis of colorectal cancer with lymph node metastasis. In view of the large diameter of the aorta, high flow, and absence of significant mural atherosclerosis, this is an intriguing finding. There is no consensus on the optimal treatment strategy,
      • Choukroun E.M.
      • Labrousse L.M.
      • Madonna F.P.
      • et al.
      Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 cases.
      but here, removal of the clot by operation and continued anticoagulant treatment was successful.

      Acknowledgments

      None.

      References

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        Mobile thromboses of the aortic arch without aortic debris: a transesophageal echocardiographic finding associated with unexplained arterial embolism.
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        Peripheral arterial ischemic events in cancer patients.
        Vasc Med. 2011; 16: 119-130
        • Falanga A.
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        • Vignoli A.
        Coagulation and cancer: biological and clinical aspects.
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        • Choukroun E.M.
        • Labrousse L.M.
        • Madonna F.P.
        • et al.
        Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 cases.
        Ann Vasc Surg. 2002; 16: 714-722