Journal of the Louisiana State Medical Society
Showers of Emboli From a Large Aortic Root Thrombus
Rami N. Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI; Laura Salama, MD; Mohamad Khaled Soufi, MD; Alim Khandekar, MD; Saleem Al-Mawed, MD
It is rare to find aortic root thrombi in the absence of aortic root aneurysmor extensive aortic atherosclerosis. Up to this date, only a few cases have been reported. The etiology has beenmainly attributed to hypercoagulable disorders. Herein, we present a case of a large thrombus obliterating the aortic root in a patient presenting with acute abdominal pain and noted to have showers of emboli to the kidneys. Hypercoagulable workup failed to reveal any congenital or acquired clotting disorder. The thrombus was thought to have developed spontaneously, and was removed surgically. Two months later, however, she had an arterial clot in the left popliteal artery that was removed surgically. The patient was seen for follow-up three and six months later and was stable with no complaints. This case highlights the importance of considering the ascending aorta as a source in cases of systemic embolization. In addition, the different diagnostic options, management protocols, and potential complica- tions are discussed.
CASE PRESENTATION A 43-year-old African-American woman with a past medical history of hypertension and diabetes mellitus, presented to the emergency room with severe right lower quadrant abdominal pain, nausea, and vomiting. Com- puted tomography (CT) of the abdomen and pelvis with contrast showedmultiple wedge-shaped foci of diminished enhancement in the lower pole of the right kidney, highly suspicious for renal infarcts. An incidental finding of a mass of low density appeared above the aortic valve. Computed tomographic (CT) scan of the chest with contrast (Figure 1) revealed a filling defect measuring 1.1 x 1.4 x 2.1 cm in the proximal ascending aorta. The mass appeared to be local- ized to the aortic root. The other cardiac valves were normal. There were no other filling defects within the ventricles or atria. The heart was normal in size. Transesophageal echocardiography (Figures 2 and 3) was done to confirm the presence of a large mass almost obliterating the aortic root. The mass was not attached to the aortic valve leaflets. The left ventricular ejection fraction was normal (>55%). A hematological consult was obtained after the patient was started on heparin. An extensive workup for coagulopa- thy/hypercoagulable status and autoimmune disorders was negative. The workup revealed the following results: plasma fibrinogen: 320 mg/dl (N: 145-348 mg/dl), prothrombin G20210A genotype analysis: normal, antithrombin III: 109%
(N: 84-125%), protein C: 150% (N: 74-161%), protein S: 56% (N: 47-134%), activated protein C resistance: 2.5 (N: >2.1), and normal Factor V leiden. Homocysteine level was normal: 9.8 mmol/L (N <12 mmol/L). Lupus anticoagulant profile was negative; anticardiolipin antibody IgG: 1.8 GPL units (N: 0-9.9 GPL units), IgM: 0.7 MPL (N: 0-9.9 MPL), and anti- beta 2 glycoprotein1 was within normal range: IgG: 0.6 U/ ml (N: 0-9.9 U/ml). Russel Viper Venom time: 36.1 sec (N: 32.2-40.1). Cytoplasmic antineutrophil cytoplasmic antibod- ies (c-ANCA): 0.61 (N: 0-0.79), Anti-dsDNA antibodies: 6 (N: 0-24.9), and Anti-Smith: 178 (N: 90-180)]. She had normal CBC: Hb: 14.1 g/dL (N: 11.5-14.8 g/dL), Hct: 43.1 % (N: 34.6-43.8%), WBC: 12,400/mcL (N: 4,200-10,200/mcL), and Platelet count: 326,000/mcL (N: 150,000-400,000/mcL). She had dyslipidemia: triglycerides: 276 mg/dL (N <150 mg/ dL), total serum cholesterol: 187 mg/dL (N: <200 mg/dL), HDL: 33 mg/dL (N: 40-60 mg/dL), and LDL: 131 mg/dL (N: <100 mg/dL). The patient denied smoking and drug use. She had no history of atrial fibrillation, deep venous thrombosis (DVT), or any other thrombus formation. She had an elevated Body Mass Index (BMI) of 33.4 (height: 157.5 cm, weight: 82.8 kg). There was no family history of coagulation or bleeding dis- orders. Her medications included atorvastatin, metoprolol, and hydrochlorothiazide, and she denied the use of any oral contraception. Both diagnoses of HTN and DMwere made prior to the initial presentation, and her diabetic control was suboptimal: HbA1C was 7.3% (N: 4.8-6%)
138 J La State Med Soc VOL 166 July/August 2014
Made with FlippingBook - Online catalogs