Background

• In the absence of diffuse atherosclerosis or aneurysms, TAMT are exceedingly rare

• Cerebral, visceral and peripheral arterial emboli are a common and debilitating clinical presentation

• The rate of repeat embolisation is unknown, but seemingly high

• Indication and timing of thoracic aortic thrombectomy are controversial

• Paucity of data describing this disorder

OBJECTIVES

To describe the clinical presentation, treatment and outcome of 13 patients with TAMT

To define a treatment strategy for patients with TAMT

Patient Population

• Between 2/96 and 7/09, 13 patients were treated with TAMT• Mean age 52 ± 13 years (8 females)• Hypercoagulable disorder/ + family history n=6• Peripheral embolectomy/thrombectomy

n=5• Diagnosis: CTA (n=11); TEE (n=12); angiography (n=1)• Intravenous heparin/ASA n=13• Thoracic Aortic Thrombectomy n=7• Medical Treatment n=5

Patient Age Presenting embolic event Coagulation Disorder RecurrentEmbolism

Location in aorta Treatment Status

1 52 Blue toe syndrome,Upper Extremity, TIA

Arch (2) Medical A

2 64 Stroke Arch Surgery A

3 46 Bilateral LE, Embolectomy/Thrombectomy

BLE, Rt BKA

Protein S Deficiency, + FH Y Distal Arch, DTA Medical D

4 42 Renal-Splenic positive FH Y Thoraco-Abdominal Surgery A

5 50 Bilateral LE Thrombocytopenia, Homocysteinemia, + FH

Thoraco-Abdominal Medical A

6 60 Blue toe syndrome positive FH Proximal DTA Surgery A

7 84 Mesenteric, stroke Arch (2) Medical D

8 48 Blue toe syndrome Y Proximal DTA Surgery A

9 36 spleen, Rt LE, Lt Upper extremities

Homocysteinemia + FH Y Proximal DTA Surgery A

10 42 splenic Thoraco-Abdominal Surgery A

11 69 Stroke Arch Medical A12 51 Mesenteric, stroke,

Bilateral LEpositive FH Y DTA Medical D

13 42 Stroke, Blue Toe Syndrome Ascending ,Distal Arch (2)

Surgery-Medical

A

PATIENT CHARACTERISTICS

• Location Ascending aorta and arch n=5 Descending aorta n=6 Descending and abdominal n=3• Localized defect in aortic wall

n=3 (isolated ulcer in 2 and aortic fossette in one)• Highly mobile (pedunculated)

n=11

Pathology

Clinical Scenario46 year-old female with a strong history of hypercoagulable disorder

presented with flank pain and hematuria. A CT angio showed a pedunculated TAMT (fig 1) and evidence of renal and splenic infarcts (fig 2). Intravenous heparin was used for 5 days followed by left thoraco-laparotomy with removal of a large aortic thrombus (clamp and sew) (fig 3). She recovered well and discharged home (warfarin/ASA) on day 7. She is alive at one year with no recurrence.

Figure 1 Figure 2 Figure 3

Surgical Procedures

1.Thoracic aortic thrombectomiesn=7• Left thoracotomy (atrial-femoral bypass) n=4• Median sternotomy with cardiopulmonary bypass n=2 (hypothermic circulatory arrest in 1)• Left thoraco-laparotomy (clamp and sew) n=1

2.Procedures for complications* n=7• Lower extremity embolectomy/thrombectomy n=2• Femoro-popliteal artery bypass n=1• Mesenteric artery embolectomy/bowel resection n=1• Lower extremity amputation n=1• Upper extremity embolectomy/thrombectomy n=1• Celiac artery embolectomy n=1* Pre-post and/or during thoracic aortic procedure

Clinical Outcomes1.Surgery n=7• Operative mortality 0%• Recurrence n=1 (8 mm suture line thrombus that resolved with anticoagulation)

• All patients alive at mean follow-up of 24 ± 16 mo

2.Medical treatment n=6• 1 patient died at presentation with stroke/mesenteric ischemia

• 6 patients at mean follow-up of 14 ± 11 mo (1 patient = 2 thrombus)• 2 patients had a fatal recurrent embolic event within 6 weeks• 2 patients had resolution of thrombus and within 4 weeks• 2 patients had a stable thrombus

Reference^^ Year Cases Diagnosis TreatmentRecurrence

(Thrombectomy)Recurrence

(Anticoagulation)

Laperche et al.^ 1997 23 TEE Operative/Medical 1/10 4/15

Lau et al. 1997 5 TEE Medical 1/4 1/4

Goueffic et al.^ 2002 38 TEE/CTA/MRI Operative 4/38 NA

Choukron et al. 2001 9 TEE/CTA Operative/Medical 1/5 0/4

Bowdisk et al. 2002 5 TEE/CTA Medical NA 0/5

Pagni et al. 2010 13 TEE/CTA/Angio Operative/Medical 1/7 3/6 *

LITERATURE

*1 patient had a thrombus in the ascending aortic (surgery) and one in the descending aorta (medical treatment)^ Multi-center study^^Only series reporting 5 or more patients

Therapeutic Strategy

• All patients are given aspirin and intravenous heparin at diagnosis

• Peripheral or visceral embolectomy if indicated

• Work-up for malignancy and pro-coagulable disorders

• If the patient is viable after initial embolic event thoracic thrombectomy within 2 weeks if no resolution of thrombus

• If initial embolic event is too morbid or surgical risk too high oral anticoagulation and CTA follow-up

• If thrombus is pedunculated (highly mobile) Early Thrombectomy

SUMMARY

• TAMT is a rare and often debilitating clinical condition

• Thoracic aortic thrombectomy can be performed at low risk

• Early intervention may prevent fatal recurrent embolic events

• Larger series are needed to better define the role of surgery and the embolic risk of these lesions