Figure 5: Arteriogram showing a filling defect in the distal left popliteal artery (arrow), obstructing flow at its bifurcation into the tibioperoneal trunk and anterior tibial artery.
tomography, 26 andmagnetic resonance imaging, 8 remain the diagnostic tools of choice in the diagnosis of aortic thrombus. The management of aortic root thrombosis is contro- versial. 6,9,11,27 Therapeutic strategies are influenced by the localization of the thrombus, the co-morbidities of the pa- tient, and the physician’s preferences. 27 Treatment options include systemic anticoagulation therapy alone, throm- bolytic therapy, 17 surgical removal of the thrombus with/ without graft replacement, and endovascular stent-grafting. Oral anticoagulation is generally considered a first- line management, unless warfarin is contraindicated or there are repetitive embolic events. 9,11 Several cases have demonstrated successful resolution of mobile aortic thrombi without further emboli with long-term oral anticoagu- lants. 10,23,28 Thrombectomy is indicated in cases of contrain- dication to anticoagulation, mobile thrombus, 11 or recurrent embolic events. 6,9,11,29,30 An aggressive surgical approach is recommended in the low-risk patient to prevent cerebro- vascular accidents and further peripheral embolization. 22,30 Some reports suggest repeat TEE two weeks after starting oral anticoagulation, when incomplete resolution of the thrombus might warrant surgical intervention, especially in young patients. 9 Some authors have advocated the use of an endovascular stent-graft (SG) whenever possible 6,11,27 be- cause the less invasive procedure may reduce perioperative morbidity andmortality. 6 Although anticoagulation seems to be preferred over a surgical approach in many cases, there are reported complications of anticoagulation. 1,10 CONCLUSION
atherosclerotic aorta are rare. The pathogenesis may be multifactorial, 6 and hypercoaguability may well play a role, even when standard coagulation studies are normal. The rarity of the lesions and difficulty in diagnosis have precluded accurate determination of the natural history and optimal treatment of this disease. To date, there are no data to advocate or to refute the use of anticoagulation prior to thrombectomy in these cases. Management should include long-term therapy with warfarin sodium and imaging sur- veillance to avoid further embolization. 9,27 REFERENCES 1. Onwuanyi A, Sachdeva R, Hamirani K, IslamM, Parris R. Multiple aortic thrombi associated with protein C and S deficiency. Mayo ClinProc 2001;76:319-322. 2. Bruno P, Massetti M, Babatasi G, Khayat A. Catastrophic consequences of a free floating thrombus in ascending aorta. Eur J Cardiothorac Surg . 2001 Jan;19(1):99-101. 3. Zavala JA, Amarrenco P, Davis SM, Jones EF, Young D, Macleod MR, Horky LL, Donnan GA. Aortic arch atheroma. Int J Stroke . 2006 May;1(2):74-80 4. Malyar NM, Janosi RA, Brkovic Z, Erbel R. Largemobile thrombus in non-atherosclerotic thoracic aorta as the source of peripheral arterial embolism. Thromb J . 2005 Nov 29;3:19. 5. Laperche T, Laurian C, Roudaut R, Steg PG: Mobile thromboses of the aortic arch without aortic debris. A transesophageal echocardiographic finding associated with unexplained arterial embolism. The Filiale Echocardiographie de la Societe Francaise de Cardiologie. Circulation 1997, 96(1):288-294 6. Piffaretti G, Tozzi M, Mariscalco G, Bacuzzi A, Lomazzi C, Rivolta N, Carrafiello G, Castelli P. Mobile thrombus of the thoracic aorta: management and treatment review. Vasc Endovascular Surg . 2008 Oct-Nov;42(5):405-11.
Thromboembolic events from a non-aneurysma, non-
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