Abstract
A primary aortic mural thrombus (PAMT) is defined as a thrombus attached to the aortic wall in the absence of any atherosclerotic or aneurysmal disease of the aorta or any cardiac source of embolus. It is a rare entity that has high morbidity and mortality. There is no consensus on the ideal treatment of PAMT. The objective of this paper is to review the possibilities for treatment of mobile abdominal aortic mural thrombus. Endovascular therapy and open surgery appear to be the best options for treatment of mobile abdominal aortic mural thrombus. Thus, in patients with favorable anatomy, endovascular therapy is probably the treatment choice, while in those with unfavorable anatomy, open surgery is probably the best option for treatment of a mobile abdominal aortic thrombus. It is important to emphasize that anticoagulation alone can be used as a non-aggressive option and, if this fails, endovascular or surgical methods can then be employed.
Keywords:
abdominal aortic mural thrombus; mural thrombi; aortic mobile thrombus; primary aortic mural thrombus; endovascular therapy
Resumo
O trombo mural aórtico primário é definido como um trombo aderido à parede aórtica na ausência de doença aterosclerótica e/ou aneurismática ou de fonte cardíaca de êmbolo. Trata-se de uma doença rara, porém causadora de alta morbimortalidade, e não há consenso acerca do seu tratamento. Este estudo objetivou revisar as possibilidades na presença de componente móvel. A terapia endovascular e a cirurgia aberta parecem ser as melhores opções, sendo a abordagem endovascular o tratamento de escolha para pacientes com anatomia favorável e a cirurgia aberta o tratamento de escolha para pacientes com anatomia desfavorável. No entanto, a anticoagulação sistêmica apresenta-se como método não invasivo para pacientes com alto risco cirúrgico e como possibilidade terapêutica na falha ou indisponibilidade de abordagem cirúrgica.
Palavras-chave:
trombo aórtico abdominal; trombo móvel aórtico; trombo mural primário; terapia endovascular; aorta abdominal
INTRODUCTION
Primary aortic mural thrombus (PAMT) was described for the first time in 1958 by Weissman and Tobin.11 Weismann RE, Tobin RW. Arterial embolism occurring during systemic heparin therapy. AMA Arch Surg. 1958;76(2):219-25, discussion 225-7. http://dx.doi.org/10.1001/archsurg.1958.01280200041005. PMid:13497418.
http://dx.doi.org/10.1001/archsurg.1958....
It is defined as a thrombus attached to the aortic wall in the absence of any atherosclerotic or aneurysmal disease in the aorta or any cardiac source of embolus. Despite being rare, this type of thrombi has high morbidity and mortality rates, considering that 17% of cases present peripheral embolization and 6% of cases evolve to death.22 Machleder HI, Takiff H, Lois JF, Holburt E. Aortic mural thrombus: an occult source of arterial thromboembolism. J Vasc Surg. 1986;4(5):473-8. http://dx.doi.org/10.1016/0741-5214(86)90383-6. PMid:3773130.
http://dx.doi.org/10.1016/0741-5214(86)9...
The first reported case series describing distal embolization caused by aortic thrombus was published in 1981, reporting 20 cases.33 Williams GM, Harrington D, Burdick J, White RI. Mural thrombus of the aorta. Ann Surg. 1981;194(6):737-44. http://dx.doi.org/10.1097/00000658-198112000-00013. PMid:7305488.
http://dx.doi.org/10.1097/00000658-19811...
The prevalence of PAMT described in the literature is 0.8 – 9.0%.44 Moris D, Karaolanis G, Schizas D, Georgopoulos S. eComment. Mural thrombus in normal appearing aorta: Unfinished saga in uncharted waters. Interact Cardiovasc Thorac Surg. 2016;22(3):373-4. http://dx.doi.org/10.1093/icvts/ivv407. PMid:26874007.
http://dx.doi.org/10.1093/icvts/ivv407...
However, considering that PAMT tends to be asymptomatic until embolization, the true prevalence of the disease is unknown and the increase in reports in recent decades is mainly due to the greater availability of imaging tests.55 Varino J, Rodrigues R, Pereira B, Moreira M, Gonçalves Ó. Aortic mural thrombus. Rev Port Cir Cardiotorac Vasc. 2019;26(1):19-26. PMid:31104372.
The pathophysiology behind PAMT in a healthy aorta is unclear. However, in the literature its presence has been associated with prothrombotic disorders like infection,66 Roche-Nagle G, Wooster D, Oreopoulos G. Symptomatic thoracic aorta mural thrombus. Vascular. 2010;18(1):41-4. http://dx.doi.org/10.2310/6670.2009.00028. PMid:20122360.
http://dx.doi.org/10.2310/6670.2009.0002...
,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
endovascular manipulation,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,88 Turley RS, Unger J, Cox MW, Lawson J, McCann RL, Shortell CK. Atypical aortic thrombus: should nonoperative management be first line? Ann Vasc Surg. 2014;28(7):1610-7. http://dx.doi.org/10.1016/j.avsg.2014.03.028. PMid:24704850.
http://dx.doi.org/10.1016/j.avsg.2014.03...
closed aortic trauma,66 Roche-Nagle G, Wooster D, Oreopoulos G. Symptomatic thoracic aorta mural thrombus. Vascular. 2010;18(1):41-4. http://dx.doi.org/10.2310/6670.2009.00028. PMid:20122360.
http://dx.doi.org/10.2310/6670.2009.0002...
,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,99 Fayad ZY, Semaan E, Fahoum B, Briggs M, Tortolani A, D’Ayala M. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282-90. http://dx.doi.org/10.1016/j.avsg.2012.03.011. PMid:22929167.
http://dx.doi.org/10.1016/j.avsg.2012.03...
,1010 Weiss S, Bühlmann R, von Allmen RS, et al. Management of floating thrombus in the aortic arch. J Thorac Cardiovasc Surg. 2016;152(3):810-7. http://dx.doi.org/10.1016/j.jtcvs.2016.03.078. PMid:27160939.
http://dx.doi.org/10.1016/j.jtcvs.2016.0...
arterial wall tumor,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,88 Turley RS, Unger J, Cox MW, Lawson J, McCann RL, Shortell CK. Atypical aortic thrombus: should nonoperative management be first line? Ann Vasc Surg. 2014;28(7):1610-7. http://dx.doi.org/10.1016/j.avsg.2014.03.028. PMid:24704850.
http://dx.doi.org/10.1016/j.avsg.2014.03...
,1111 Meyermann K, Trani J, Caputo FJ, Lombardi JV. Descending thoracic aortic mural thrombus presentation and treatment strategies. J Vasc Surg. 2017;66(3):931-6. http://dx.doi.org/10.1016/j.jvs.2017.05.109. PMid:28754361.
http://dx.doi.org/10.1016/j.jvs.2017.05....
,1212 Aldaher MK, El-Fayed HM, Malouka SA, Gad FS. Large aortic arch mural thrombus in non-atherosclerotic thoracic aorta--a rare cause of stroke in the young. BMJ Case Rep. 2015;2015(nov19 1):bcr2015212887. http://dx.doi.org/10.1136/bcr-2015-212887. PMid:26584908.
http://dx.doi.org/10.1136/bcr-2015-21288...
occult neoplasm,66 Roche-Nagle G, Wooster D, Oreopoulos G. Symptomatic thoracic aorta mural thrombus. Vascular. 2010;18(1):41-4. http://dx.doi.org/10.2310/6670.2009.00028. PMid:20122360.
http://dx.doi.org/10.2310/6670.2009.0002...
7 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
8 Turley RS, Unger J, Cox MW, Lawson J, McCann RL, Shortell CK. Atypical aortic thrombus: should nonoperative management be first line? Ann Vasc Surg. 2014;28(7):1610-7. http://dx.doi.org/10.1016/j.avsg.2014.03.028. PMid:24704850.
http://dx.doi.org/10.1016/j.avsg.2014.03...
9 Fayad ZY, Semaan E, Fahoum B, Briggs M, Tortolani A, D’Ayala M. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282-90. http://dx.doi.org/10.1016/j.avsg.2012.03.011. PMid:22929167.
http://dx.doi.org/10.1016/j.avsg.2012.03...
10 Weiss S, Bühlmann R, von Allmen RS, et al. Management of floating thrombus in the aortic arch. J Thorac Cardiovasc Surg. 2016;152(3):810-7. http://dx.doi.org/10.1016/j.jtcvs.2016.03.078. PMid:27160939.
http://dx.doi.org/10.1016/j.jtcvs.2016.0...
-1111 Meyermann K, Trani J, Caputo FJ, Lombardi JV. Descending thoracic aortic mural thrombus presentation and treatment strategies. J Vasc Surg. 2017;66(3):931-6. http://dx.doi.org/10.1016/j.jvs.2017.05.109. PMid:28754361.
http://dx.doi.org/10.1016/j.jvs.2017.05....
,1313 Piffaretti G, Tozzi M, Caronno R, Castelli P. Endovascular treatment for mobile thrombus of the thoracic aorta. Eur J Cardiothorac Surg. 2007;32(4):664-6. http://dx.doi.org/10.1016/j.ejcts.2007.06.043. PMid:17689971.
http://dx.doi.org/10.1016/j.ejcts.2007.0...
14 Verma H, Meda N, Vora S, George RK, Tripathi RK. Contemporary management of symptomatic primary aortic mural thrombus. J Vasc Surg. 2014;60(6):1524-34. http://dx.doi.org/10.1016/j.jvs.2014.08.057. PMid:25256613.
http://dx.doi.org/10.1016/j.jvs.2014.08....
-1515 Boufi M, Mameli A, Compes P, Hartung O, Alimi YS. Elective stent-graft treatment for the management of thoracic aorta mural thrombus. J Vasc Surg. 2014;59(4):1177. http://dx.doi.org/10.1016/j.jvs.2014.02.023.
http://dx.doi.org/10.1016/j.jvs.2014.02....
chemotherapy,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,1616 Yagyu T, Naito M, Kumada M, Nakagawa T. Aortic mural thrombus in the non-atherosclerotic aorta of patients with multiple hypercoagulable factors. Intern Med. 2019;58(3):381-5. http://dx.doi.org/10.2169/internalmedicine.0691-17. PMid:30210102.
http://dx.doi.org/10.2169/internalmedici...
hereditary thrombophilias,33 Williams GM, Harrington D, Burdick J, White RI. Mural thrombus of the aorta. Ann Surg. 1981;194(6):737-44. http://dx.doi.org/10.1097/00000658-198112000-00013. PMid:7305488.
http://dx.doi.org/10.1097/00000658-19811...
,66 Roche-Nagle G, Wooster D, Oreopoulos G. Symptomatic thoracic aorta mural thrombus. Vascular. 2010;18(1):41-4. http://dx.doi.org/10.2310/6670.2009.00028. PMid:20122360.
http://dx.doi.org/10.2310/6670.2009.0002...
,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,99 Fayad ZY, Semaan E, Fahoum B, Briggs M, Tortolani A, D’Ayala M. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282-90. http://dx.doi.org/10.1016/j.avsg.2012.03.011. PMid:22929167.
http://dx.doi.org/10.1016/j.avsg.2012.03...
,1717 Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromboses of the aortic arch without aortic debris. Circulation. 1997;96(1):288-94. http://dx.doi.org/10.1161/01.CIR.96.1.288. PMid:9236447.
http://dx.doi.org/10.1161/01.CIR.96.1.28...
,1818 Sabetai MM, Conway AM, Hallward G, Bapat V. Ascending aorta thrombus adjacent to a cholesterol-rich plaque as the source of multiple emboli. Interact Cardiovasc Thorac Surg. 2013;16(3):389-90. http://dx.doi.org/10.1093/icvts/ivs490. PMid:23243036.
http://dx.doi.org/10.1093/icvts/ivs490...
essential thrombocytosis,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,1111 Meyermann K, Trani J, Caputo FJ, Lombardi JV. Descending thoracic aortic mural thrombus presentation and treatment strategies. J Vasc Surg. 2017;66(3):931-6. http://dx.doi.org/10.1016/j.jvs.2017.05.109. PMid:28754361.
http://dx.doi.org/10.1016/j.jvs.2017.05....
,1515 Boufi M, Mameli A, Compes P, Hartung O, Alimi YS. Elective stent-graft treatment for the management of thoracic aorta mural thrombus. J Vasc Surg. 2014;59(4):1177. http://dx.doi.org/10.1016/j.jvs.2014.02.023.
http://dx.doi.org/10.1016/j.jvs.2014.02....
polycythemia,66 Roche-Nagle G, Wooster D, Oreopoulos G. Symptomatic thoracic aorta mural thrombus. Vascular. 2010;18(1):41-4. http://dx.doi.org/10.2310/6670.2009.00028. PMid:20122360.
http://dx.doi.org/10.2310/6670.2009.0002...
,1111 Meyermann K, Trani J, Caputo FJ, Lombardi JV. Descending thoracic aortic mural thrombus presentation and treatment strategies. J Vasc Surg. 2017;66(3):931-6. http://dx.doi.org/10.1016/j.jvs.2017.05.109. PMid:28754361.
http://dx.doi.org/10.1016/j.jvs.2017.05....
antiphospholipid syndrome,44 Moris D, Karaolanis G, Schizas D, Georgopoulos S. eComment. Mural thrombus in normal appearing aorta: Unfinished saga in uncharted waters. Interact Cardiovasc Thorac Surg. 2016;22(3):373-4. http://dx.doi.org/10.1093/icvts/ivv407. PMid:26874007.
http://dx.doi.org/10.1093/icvts/ivv407...
,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,1515 Boufi M, Mameli A, Compes P, Hartung O, Alimi YS. Elective stent-graft treatment for the management of thoracic aorta mural thrombus. J Vasc Surg. 2014;59(4):1177. http://dx.doi.org/10.1016/j.jvs.2014.02.023.
http://dx.doi.org/10.1016/j.jvs.2014.02....
hyperhomocysteinemia,77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,99 Fayad ZY, Semaan E, Fahoum B, Briggs M, Tortolani A, D’Ayala M. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282-90. http://dx.doi.org/10.1016/j.avsg.2012.03.011. PMid:22929167.
http://dx.doi.org/10.1016/j.avsg.2012.03...
,1515 Boufi M, Mameli A, Compes P, Hartung O, Alimi YS. Elective stent-graft treatment for the management of thoracic aorta mural thrombus. J Vasc Surg. 2014;59(4):1177. http://dx.doi.org/10.1016/j.jvs.2014.02.023.
http://dx.doi.org/10.1016/j.jvs.2014.02....
familial dysfibrinogenemia77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,1515 Boufi M, Mameli A, Compes P, Hartung O, Alimi YS. Elective stent-graft treatment for the management of thoracic aorta mural thrombus. J Vasc Surg. 2014;59(4):1177. http://dx.doi.org/10.1016/j.jvs.2014.02.023.
http://dx.doi.org/10.1016/j.jvs.2014.02....
and heparin-induced thrombocytopenia.77 Tsilimparis N, Hanack U, Pisimisis G, Yousefi S, Wintzer C, Rückert RI. Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta – an unusual source of arterial embolism. Eur J Vasc Endovasc Surg. 2011;41(4):450-7. http://dx.doi.org/10.1016/j.ejvs.2010.11.004. PMid:21145267.
http://dx.doi.org/10.1016/j.ejvs.2010.11...
,1010 Weiss S, Bühlmann R, von Allmen RS, et al. Management of floating thrombus in the aortic arch. J Thorac Cardiovasc Surg. 2016;152(3):810-7. http://dx.doi.org/10.1016/j.jtcvs.2016.03.078. PMid:27160939.
http://dx.doi.org/10.1016/j.jtcvs.2016.0...
As previously stated, the clinical presentation of PAMT is usually asymptomatic until embolization occurs.55 Varino J, Rodrigues R, Pereira B, Moreira M, Gonçalves Ó. Aortic mural thrombus. Rev Port Cir Cardiotorac Vasc. 2019;26(1):19-26. PMid:31104372. A review of thoracic PAMT showed that 82% were diagnosed after embolization.1111 Meyermann K, Trani J, Caputo FJ, Lombardi JV. Descending thoracic aortic mural thrombus presentation and treatment strategies. J Vasc Surg. 2017;66(3):931-6. http://dx.doi.org/10.1016/j.jvs.2017.05.109. PMid:28754361.
http://dx.doi.org/10.1016/j.jvs.2017.05....
Regarding the prevalence in different genders, the male to female ratio is 1:199 Fayad ZY, Semaan E, Fahoum B, Briggs M, Tortolani A, D’Ayala M. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282-90. http://dx.doi.org/10.1016/j.avsg.2012.03.011. PMid:22929167.
http://dx.doi.org/10.1016/j.avsg.2012.03...
and the average age of diagnosis varies between 40 and 56 years.1010 Weiss S, Bühlmann R, von Allmen RS, et al. Management of floating thrombus in the aortic arch. J Thorac Cardiovasc Surg. 2016;152(3):810-7. http://dx.doi.org/10.1016/j.jtcvs.2016.03.078. PMid:27160939.
http://dx.doi.org/10.1016/j.jtcvs.2016.0...
,1414 Verma H, Meda N, Vora S, George RK, Tripathi RK. Contemporary management of symptomatic primary aortic mural thrombus. J Vasc Surg. 2014;60(6):1524-34. http://dx.doi.org/10.1016/j.jvs.2014.08.057. PMid:25256613.
http://dx.doi.org/10.1016/j.jvs.2014.08....
,1515 Boufi M, Mameli A, Compes P, Hartung O, Alimi YS. Elective stent-graft treatment for the management of thoracic aorta mural thrombus. J Vasc Surg. 2014;59(4):1177. http://dx.doi.org/10.1016/j.jvs.2014.02.023.
http://dx.doi.org/10.1016/j.jvs.2014.02....
The most common embolization sites are the lower limbs, followed by the visceral arteries and the brain.1414 Verma H, Meda N, Vora S, George RK, Tripathi RK. Contemporary management of symptomatic primary aortic mural thrombus. J Vasc Surg. 2014;60(6):1524-34. http://dx.doi.org/10.1016/j.jvs.2014.08.057. PMid:25256613.
http://dx.doi.org/10.1016/j.jvs.2014.08....
Verma’s anatomical classification of PAMT divides it into four types (Figure 1 and Table 1).1414 Verma H, Meda N, Vora S, George RK, Tripathi RK. Contemporary management of symptomatic primary aortic mural thrombus. J Vasc Surg. 2014;60(6):1524-34. http://dx.doi.org/10.1016/j.jvs.2014.08.057. PMid:25256613.
http://dx.doi.org/10.1016/j.jvs.2014.08....
In addition to classification by location, these thrombi can also be classified by their morphology. Eccentric or concentric thrombi with no free floating component are classified as Sessile (S). Mural thrombi attached to the aorta proximally with a distal free floating segment of variable length are classified as Pedunculated (P). Complete thrombotic occlusion of the aorta is classified as Occlusion (O).
There is no consensus on the ideal treatment for PAMT. The objective of this narrative review is to evaluate the best treatment for mobile abdominal aortic thrombi classified as types III or IV.
METHODS
Inclusion criteria
All articles that enrolled subjects with mobile thrombus of the abdominal aorta and described their management were included.
Exclusion criteria
Studies involving just the thoracic aorta were excluded.
Literature search
Independent electronic searches were performed by two reviewers (AM and LB) on the following databases: MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, ERIC, and SciELO.
The search strategy used for Medline (PubMed) was as follows: mobile aortic thromb* AND (treatment OR management) and primary aortic mural thromb* AND (treatment OR management). These terms were adapted for use on other databases in accordance with their specific features or requirements.
No restrictions on language or date of publications were applied for any of the databases. The reference lists of all studies included were hand searched to identify potential data sources.
Selection of studies
Eligibility of studies was assessed by two authors (AM and LB). Titles and abstracts were screened for inclusion. Following that, studies that seemed fit for inclusion and studies that could not be categorized due to lack of information in the abstract underwent full text screening by the same authors.
The few disagreements that occurred during the study selection process were mainly resolved by consensus.
RESULTS
Treatment options for aortic thrombi described in the literature include primary disease anticoagulation, thrombolysis, thromboaspiration, surgical thrombectomy, and endovascular or open surgery to exclude the thrombus from the aorta (Tables 2 and 3). However, these reports are limited and the best treatment for each case and for prevention of peripheral embolization is not well established.
Articles evaluating the surgical and endovascular treatment of abdominal aortic mural thrombus.
Systemic anticoagulation is a widespread treatment for aortic thrombus in general. Tunick and Kronzon describe an important decrease in mortality in patients with aortic thrombi with a mobile component, without evidence of a reduction in embolic events. However, the need for more robust studies is emphasized.3535 Tunick PA, Kronzon I. Embolism from the aorta: atheroemboli and thromboemboli. Curr Treat Options Cardiovasc Med. 2001;3(3):181-6. http://dx.doi.org/10.1007/s11936-001-0036-3. PMid:11341863.
http://dx.doi.org/10.1007/s11936-001-003...
Saric and Kronzon3636 Saric M, Kronzon I. Aortic atherosclerosis and embolic events. Curr Cardiol Rep. 2012;14(3):342-9. http://dx.doi.org/10.1007/s11886-012-0261-2. PMid:22437371.
http://dx.doi.org/10.1007/s11886-012-026...
highlight the paucity of data regarding all therapies and the benefits or not of anticoagulation.
Caron and Anand2222 Caron F, Anand SS. Antithrombotic therapy in aortic diseases: a narrative review. Vasc Med. 2017;22(1):57-65. http://dx.doi.org/10.1177/1358863X16675229. PMid:28215108.
http://dx.doi.org/10.1177/1358863X166752...
reported a case treated successfully with warfarin anticoagulation. This choice was made because of impaired renal function, which is a relative contraindication for endovascular therapy. Use of systemic anticoagulation is also strongly supported by Hahn et al, Bowdish et al., Patrício et al., Valdivia et al. and Poirée et al., whose patients didn’t present thrombus recurrence or re-embolization. The surgical approach was only indicated for patients who do not respond to conservative treatment.1919 Hahn TL, Dalsing MC, Sawchuk AP, Cikrit DF, Lalka SG. Primary aortic mural thrombus: presentation and treatment. Ann Vasc Surg. 1999;13(1):52-9. http://dx.doi.org/10.1007/s100169900220. PMid:9878657.
http://dx.doi.org/10.1007/s100169900220...
20 Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713-9. http://dx.doi.org/10.1016/S0741-5214(02)00123-4. PMid:12368731.
http://dx.doi.org/10.1016/S0741-5214(02)...
-2121 Poirée S, Monnier-Cholley L, Tubiana J-M, Arrivé L. Acute abdominal aortic thrombosis in cancer patients. Abdom Imaging. 2004;29(4):511-3. http://dx.doi.org/10.1007/s00261-003-0144-5. PMid:15024514.
http://dx.doi.org/10.1007/s00261-003-014...
,2323 Reyes Valdivia A, Duque Santos A, Garnica Ureña M, et al. Anticoagulation alone for aortic segment treatment in symptomatic primary aortic mural thrombus patients. Ann Vasc Surg. 2017;43:121-6. http://dx.doi.org/10.1016/j.avsg.2017.01.005. PMid:28258017.
http://dx.doi.org/10.1016/j.avsg.2017.01...
,2424 Patrício C, Silva MM, Silva PE, Oliveira J, Bagulho L. Massive organ embolization from primary aortic thrombosis. Rev Port Cardiol. 2018;37(5):447.e1-6. http://dx.doi.org/10.1016/j.repc.2017.02.020. PMid:29709406.
http://dx.doi.org/10.1016/j.repc.2017.02...
Regarding the choice of anticoagulation drug, most studies used unfractionated heparin (UFH) for a short period of time and then switched to warfarin,2020 Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713-9. http://dx.doi.org/10.1016/S0741-5214(02)00123-4. PMid:12368731.
http://dx.doi.org/10.1016/S0741-5214(02)...
,2222 Caron F, Anand SS. Antithrombotic therapy in aortic diseases: a narrative review. Vasc Med. 2017;22(1):57-65. http://dx.doi.org/10.1177/1358863X16675229. PMid:28215108.
http://dx.doi.org/10.1177/1358863X166752...
,2424 Patrício C, Silva MM, Silva PE, Oliveira J, Bagulho L. Massive organ embolization from primary aortic thrombosis. Rev Port Cardiol. 2018;37(5):447.e1-6. http://dx.doi.org/10.1016/j.repc.2017.02.020. PMid:29709406.
http://dx.doi.org/10.1016/j.repc.2017.02...
,2525 DeKornfeld GM, Boll J, Ziegler KR, et al. Initial and intermediate-term treatment of the phantom thrombus (primary non-occlusive mural thrombus on normal arteries). Vasc Med. 2018;23(6):549-54. http://dx.doi.org/10.1177/1358863X18788952. PMid:30124120.
http://dx.doi.org/10.1177/1358863X187889...
targeting an international normalized ratio (INR) between 2 and 32020 Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713-9. http://dx.doi.org/10.1016/S0741-5214(02)00123-4. PMid:12368731.
http://dx.doi.org/10.1016/S0741-5214(02)...
,2525 DeKornfeld GM, Boll J, Ziegler KR, et al. Initial and intermediate-term treatment of the phantom thrombus (primary non-occlusive mural thrombus on normal arteries). Vasc Med. 2018;23(6):549-54. http://dx.doi.org/10.1177/1358863X18788952. PMid:30124120.
http://dx.doi.org/10.1177/1358863X187889...
or 2.5 and 3.5.2424 Patrício C, Silva MM, Silva PE, Oliveira J, Bagulho L. Massive organ embolization from primary aortic thrombosis. Rev Port Cardiol. 2018;37(5):447.e1-6. http://dx.doi.org/10.1016/j.repc.2017.02.020. PMid:29709406.
http://dx.doi.org/10.1016/j.repc.2017.02...
The duration of treatment remains uncertain and should be individualized, ranging from 4 months to lifelong for patients with a history of hypercoagulable state.1919 Hahn TL, Dalsing MC, Sawchuk AP, Cikrit DF, Lalka SG. Primary aortic mural thrombus: presentation and treatment. Ann Vasc Surg. 1999;13(1):52-9. http://dx.doi.org/10.1007/s100169900220. PMid:9878657.
http://dx.doi.org/10.1007/s100169900220...
,2020 Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713-9. http://dx.doi.org/10.1016/S0741-5214(02)00123-4. PMid:12368731.
http://dx.doi.org/10.1016/S0741-5214(02)...
One patient was maintained on 100 mg aspirin alone after a warfarin regimen.2525 DeKornfeld GM, Boll J, Ziegler KR, et al. Initial and intermediate-term treatment of the phantom thrombus (primary non-occlusive mural thrombus on normal arteries). Vasc Med. 2018;23(6):549-54. http://dx.doi.org/10.1177/1358863X18788952. PMid:30124120.
http://dx.doi.org/10.1177/1358863X187889...
One patient received UFH for 24-48 hours, followed by low molecular weight heparin (LMWH) for 1 month, then acenoucumarol to maintain INR in the range of 2-3.2323 Reyes Valdivia A, Duque Santos A, Garnica Ureña M, et al. Anticoagulation alone for aortic segment treatment in symptomatic primary aortic mural thrombus patients. Ann Vasc Surg. 2017;43:121-6. http://dx.doi.org/10.1016/j.avsg.2017.01.005. PMid:28258017.
http://dx.doi.org/10.1016/j.avsg.2017.01...
One patient used enoxaparin and the target dose used was based on antifactor Xa level, 0.3 to 0.8 units.2020 Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713-9. http://dx.doi.org/10.1016/S0741-5214(02)00123-4. PMid:12368731.
http://dx.doi.org/10.1016/S0741-5214(02)...
However, a high rate of thrombus recurrence and maintenance by conservative therapy was observed in a review study published in 2019, which thus recommended endovascular surgery for type IV thrombi and exploratory laparotomy for type III.55 Varino J, Rodrigues R, Pereira B, Moreira M, Gonçalves Ó. Aortic mural thrombus. Rev Port Cir Cardiotorac Vasc. 2019;26(1):19-26. PMid:31104372.
A systematic review with meta-analysis about thrombi in general – including thrombi of the thoracic and the abdominal aorta – reported 28 of 200 patients with abdominal aortic thrombus and 176 with a mobile component. In that study, anticoagulation was used for 112 patients and this subset presented more thrombus recurrence, more thrombus maintenance, and more major limb amputations than the surgical group, with 25% requiring surgery later. Treatment, complications, and recurrence were not reported by location type of the thrombus and the study did not include endovascular or thrombolytic therapies.99 Fayad ZY, Semaan E, Fahoum B, Briggs M, Tortolani A, D’Ayala M. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282-90. http://dx.doi.org/10.1016/j.avsg.2012.03.011. PMid:22929167.
http://dx.doi.org/10.1016/j.avsg.2012.03...
Two cases of type IV mobile aortic thrombus treated with thrombolytic therapy were described in 2000. One patient had the catheter positioned in a popliteal thrombus, but the aortic thrombus remained unchanged after 12 hours of continuous infusion. She was then prescribed anticoagulation because she refused a surgical procedure. Warfarin was discontinued after 6 months and 54 months later the patient remained asymptomatic and without thrombi recurrence. The second patient was successfully treated with thrombolytic therapy, using a catheter directed to the aortic thrombus, but developed massive colonic bleeding. No additional anticoagulation or surgery was needed at 36 months of follow-up. Both patients were treated with urikynase.2727 Dougherty MJ, Calligaro KD, Rua I, Delaurentis DA. Idiopathic pedunculated mural thrombus of the nonaneurysmal infrarenal aorta presenting with popliteal embolization: two cases treated with thrombolytic therapy. J Vasc Surg. 2000;32(2):383-7. http://dx.doi.org/10.1067/mva.2000.106947. PMid:10917999.
http://dx.doi.org/10.1067/mva.2000.10694...
There is no evidence for use of antiplatelet agents and statins for prevention of embolism.3535 Tunick PA, Kronzon I. Embolism from the aorta: atheroemboli and thromboemboli. Curr Treat Options Cardiovasc Med. 2001;3(3):181-6. http://dx.doi.org/10.1007/s11936-001-0036-3. PMid:11341863.
http://dx.doi.org/10.1007/s11936-001-003...
Some cases with different surgical approaches are mentioned in the literature. Of these, as early as 1999, Reber et al. reported four cases effectively treated with transabdominal endarterectomy, with no evidence of new embolic events or recurrence of thrombus over 4-24 months of follow-up. The authors suggested operative approaches are the best option if the patient presents with low surgical risk.2626 Reber PU, Patel AG, Stauffer E, Müller MF, Do DD, Kniemeyer HW. Mural aortic thrombi: an important cause of peripheral embolization. J Vasc Surg. 1999;30(6):1084-9. http://dx.doi.org/10.1016/S0741-5214(99)70047-9. PMid:10587393.
http://dx.doi.org/10.1016/S0741-5214(99)...
A similar result was observed by Bosma et al. in a case of infrarenal thrombus with embolization to the right kidney, left deep femoral artery, and lateral branches of the inferior mesenteric artery in a patient with elevated factor VIII. In this case, major amputation, hemicolectomy, and crural vessel thrombolysis were associated with transabdominal thrombectomy and life-long use of warfarin.2828 Bosma J, Rijbroek A, Rauwerda JA. A rare case of thromboembolism in a 21-year old female with elevated factor VIII. Eur J Vasc Endovasc Surg. 2007;34(5):592-4. http://dx.doi.org/10.1016/j.ejvs.2007.05.019. PMid:17669671.
http://dx.doi.org/10.1016/j.ejvs.2007.05...
In a retrospective study of patients with a history of distal embolization, three cases of primary abdominal aortic thrombus with a mobile component were found, 1 type III and 2 type IV. For the patient with PAMT type III, trapdoor aortic thrombectomy was used to treat visceral aorta involvement in the emergency setting with full recovery and no recurrence. To treat the type IV thrombi, in one patient aortoiliac embolectomy was performed and in the other exclusion by stent graft was achieved using a 16x12x70 mm Excluder limb (W. L. Gore, Flagstaff, Ariz). They had 6 month-follow-up without complications.1414 Verma H, Meda N, Vora S, George RK, Tripathi RK. Contemporary management of symptomatic primary aortic mural thrombus. J Vasc Surg. 2014;60(6):1524-34. http://dx.doi.org/10.1016/j.jvs.2014.08.057. PMid:25256613.
http://dx.doi.org/10.1016/j.jvs.2014.08....
Although recent, endovascular therapy is promising and has low rates of recurrence and re-embolization. The first case reported in the literature was performed in 2008 in a patient with a descending thoracic aortic thrombus and infrarenal aortic thrombus. A staged procedure was planned to reduce the risk of complications. The thoracic thrombus was treated first, because of the higher risk of embolization. Then, one week later, the infrarenal thrombus was excluded using a bifurcated Gore Excluder abdominal aortic stent graft (Gore-Tex, W. L. Gore & Assoc., Flagstaff, Ariz.). After nine months of follow up, the patient remained free from complications.2929 Zhang WW, Abou-Zamzam AM, Hashisho M, Killeen JD, Bianchi C, Teruya TH. Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization. J Vasc Surg. 2008;47(1):193-6. http://dx.doi.org/10.1016/j.jvs.2007.07.050. PMid:18178473.
http://dx.doi.org/10.1016/j.jvs.2007.07....
In the following year, 2 cases were reported by Luckeroth et al., treated using a 20 mm x 3.75 cm AneuRx aortic cuff (Medtronic, Minneapolis, MN) and post dilation with a 27 mm XXL balloon (Boston Scientific, Natick, MA) for one case and a 16 mm x 14 mm x 7 cm Gore Excluder contralateral leg endoprosthesis (WL Gore, Flagstaff, AZ) and post dilation with a 14 x 40 mm percutaneous transluminal angioplasty (PTA) balloon for the other case, both with distal embolectomy. In these cases, balloon exclusion of the contralateral iliac artery was performed during the procedure to reduce the risk of embolization. Follow-up was for 36 and 6 months, respectively, and both patients remained asymptomatic.3030 Luckeroth P, Steppacher R, Rohrer MJ, Eslami MH. Endovascular therapy for symptomatic mobile thrombus of infrarenal abdominal aorta. Vasc Endovascular Surg. 2009;43(5):518-23. http://dx.doi.org/10.1177/1538574409334823. PMid:19628513.
http://dx.doi.org/10.1177/15385744093348...
Endovascular surgery seems to be an option when conservative treatment isn’t successful, as observed in a patient with antiphospholipid syndrome treated with 100 mg of aspirin plus 75 mg of clopidogrel and heparin. Kadoya et al. describe use of three 40-mm-long stents (Palmaz XL stent; Cordis, Milpitas, California) with good results after 12 months of follow-up.3232 Kadoya Y, Zen K, Oda Y, Matoba S. Successful endovascular treatment for aortic thrombosis due to primary antiphospholipid syndrome: a case report and literature review. Vasc Endovascular Surg. 2019;53(1):51-7. http://dx.doi.org/10.1177/1538574418791355. PMid:30092725.
http://dx.doi.org/10.1177/15385744187913...
Furthermore, Borghese et al. recently reported three cases of mobile aortic thrombus. Treatment of an infrarenal thrombus was attempted with anticoagulation plus antiplatelet agent, but subsequent surgical placement of a 16x40 mm stent and 8 x 37 mm biiliac bare metal stent express (Boston Scientific, Natick, Mass) was needed because of thrombus maintenance. For treatment of type III thrombi, one patient underwent aortic bypass and the other received a prosthetic aortic and renal by-pass after unsuccessful open balloon thrombectomy. Both were maintained on antiplatelet therapy.3434 Borghese O, Pisani A, Di Centa I. Symptomatic aortic mural thrombus treatment and outcomes. Ann Vasc Surg. 2020;69:373-81. http://dx.doi.org/10.1016/j.avsg.2020.06.007. PMid:32554193.
http://dx.doi.org/10.1016/j.avsg.2020.06...
In addition, hybrid surgical treatment using wire-directed balloon catheter thrombectomy was reported in a patient who had undergone a complex surgical procedure 17 days earlier and received an initial UFH infusion. In this case, it was necessary to conduct mechanical thrombectomy using a Trerotola device (Arrow International Inc.) with a 5F rotating nitinol basket fragmentation cage, because of the resistance of the thrombus to the balloon.3131 Kim WC, Hong KC, Kim JY, Cho SG, Jeon YS. Successful hybrid operation of an acute mobile thrombus in the abdominal aorta induced by chemotherapy. J Korean Surg Soc. 2011;81(Suppl 1):S78-81. http://dx.doi.org/10.4174/jkss.2011.81.Suppl1.S78. PMid:22319746.
http://dx.doi.org/10.4174/jkss.2011.81.S...
Regarding percutaneous thrombectomy, a series of 3 cases was described in 2019. One patient had a visceral mobile aortic thrombus, 1 had infrarenal aorta involvement, and the third had involvement of both segments, with 2 mobile thrombi. A continuous aspiration system was used (Indigo mechanical thrombectomy system; Penumbra, Alameda, Calif) to perform the thrombectomy, in combination with real-time intravascular ultrasound (IVUS) guidance. Patients were followed for 1 month and had no residual thrombi, recurrence, or new thrombotic events.3333 Murter CD, Sigdel A, Dwivedi AJ, Wayne EJ. Percutaneous thrombectomy of mural aortic thrombus using intravascular ultrasound guidance. J Vasc Surg Cases Innov Tech. 2019;5(4):472-6. http://dx.doi.org/10.1016/j.jvscit.2019.06.013. PMid:31763501.
http://dx.doi.org/10.1016/j.jvscit.2019....
DISCUSSION
The most frequently reported type of PAMT was type II (38%). The literature on PAMT type III and IV is scarce. The narrative, systematic, and meta-analysis articles published cover treatment of PAMT as a single entity and do not segment it by affected area. This review was conducted with the aim of elucidating the treatment options for mobile abdominal aortic thrombus.
Anticoagulation is considered the therapy of choice by many authors and vascular surgeons. The anticoagulants of choice were low-molecular-weight heparin or unfractionated heparin, later switching to warfarin at hospital discharge. There is one case of thoracic mobile thrombus treated with direct oral anticoagulants with success3333 Murter CD, Sigdel A, Dwivedi AJ, Wayne EJ. Percutaneous thrombectomy of mural aortic thrombus using intravascular ultrasound guidance. J Vasc Surg Cases Innov Tech. 2019;5(4):472-6. http://dx.doi.org/10.1016/j.jvscit.2019.06.013. PMid:31763501.
http://dx.doi.org/10.1016/j.jvscit.2019....
and one case of a sessile thrombus of aorta that was treated with embolectomy. At hospital discharge, direct oral anticoagulant was prescribed with complete resolution after 2 years.3737 Mando R, Gemayel R, Chaddha A, Barbat JJ, Cami E. Peripherally embolizing aortic thrombus: the work-up, management, and outcome of primary aortic thrombus. Case Rep Cardiol. 2019;2019:8132578. http://dx.doi.org/10.1155/2019/8132578. PMid:31355013.
http://dx.doi.org/10.1155/2019/8132578...
The meta-analysis published by Fayad et al.99 Fayad ZY, Semaan E, Fahoum B, Briggs M, Tortolani A, D’Ayala M. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282-90. http://dx.doi.org/10.1016/j.avsg.2012.03.011. PMid:22929167.
http://dx.doi.org/10.1016/j.avsg.2012.03...
does not differentiate between treatment for thrombi of the thoracic or abdominal aorta and excludes endovascular treatment. In the comparison of anticoagulation versus surgical treatment, surgical treatment demonstrated benefits in the outcomes thrombus persistence and recurrence, distal embolization, complications, and limb loss. Thus, surgical treatment seems to be a superior option to use of anticoagulants for treatment of PAMT.
Regarding endovascular treatment in patients with abdominal aortic thrombus, there are no studies comparing endovascular approaches with open surgical treatment. The evidence that currently exists for endovascular treatment derives from case reports and retrospective studies. The endovascular approach seems to be the best option in cases of infrarenal and pararenal abdominal aortic thrombus. All cases treated with endovascular therapy had favorable outcomes.1414 Verma H, Meda N, Vora S, George RK, Tripathi RK. Contemporary management of symptomatic primary aortic mural thrombus. J Vasc Surg. 2014;60(6):1524-34. http://dx.doi.org/10.1016/j.jvs.2014.08.057. PMid:25256613.
http://dx.doi.org/10.1016/j.jvs.2014.08....
,2929 Zhang WW, Abou-Zamzam AM, Hashisho M, Killeen JD, Bianchi C, Teruya TH. Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization. J Vasc Surg. 2008;47(1):193-6. http://dx.doi.org/10.1016/j.jvs.2007.07.050. PMid:18178473.
http://dx.doi.org/10.1016/j.jvs.2007.07....
30 Luckeroth P, Steppacher R, Rohrer MJ, Eslami MH. Endovascular therapy for symptomatic mobile thrombus of infrarenal abdominal aorta. Vasc Endovascular Surg. 2009;43(5):518-23. http://dx.doi.org/10.1177/1538574409334823. PMid:19628513.
http://dx.doi.org/10.1177/15385744093348...
31 Kim WC, Hong KC, Kim JY, Cho SG, Jeon YS. Successful hybrid operation of an acute mobile thrombus in the abdominal aorta induced by chemotherapy. J Korean Surg Soc. 2011;81(Suppl 1):S78-81. http://dx.doi.org/10.4174/jkss.2011.81.Suppl1.S78. PMid:22319746.
http://dx.doi.org/10.4174/jkss.2011.81.S...
-3232 Kadoya Y, Zen K, Oda Y, Matoba S. Successful endovascular treatment for aortic thrombosis due to primary antiphospholipid syndrome: a case report and literature review. Vasc Endovascular Surg. 2019;53(1):51-7. http://dx.doi.org/10.1177/1538574418791355. PMid:30092725.
http://dx.doi.org/10.1177/15385744187913...
It is important to emphasize that endovascular treatment has been increasingly used for thoracic aortic thrombus and appears to be an effective and safe option.2929 Zhang WW, Abou-Zamzam AM, Hashisho M, Killeen JD, Bianchi C, Teruya TH. Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization. J Vasc Surg. 2008;47(1):193-6. http://dx.doi.org/10.1016/j.jvs.2007.07.050. PMid:18178473.
http://dx.doi.org/10.1016/j.jvs.2007.07....
,3838 Jariwala P, Kale SS. Resolution of primary aortic thrombosis after dabigatran therapy-a new hope for the rare and old disease. Indian Heart J. 2019;71(2):166-9. http://dx.doi.org/10.1016/j.ihj.2019.03.005. PMid:31280831.
http://dx.doi.org/10.1016/j.ihj.2019.03....
39 Luebke T, Aleksic M, Brunkwall J. Endovascular therapy of a symptomatic mobile thrombus of the thoracic aorta. Eur J Vasc Endovasc Surg. 2008;36(5):550-2. http://dx.doi.org/10.1016/j.ejvs.2008.07.004. PMid:18722794.
http://dx.doi.org/10.1016/j.ejvs.2008.07...
40 Altenbernd J, Schürmann K, Walterbusch G. Stentgraft-therapie bei mobilem thrombus in der thorakalen aorta. RoFo Fortschr Geb Rontgenstr Nuklearmed. 2008;180(2):158-9. http://dx.doi.org/10.1055/s-2007-963699. PMid:18058639.
http://dx.doi.org/10.1055/s-2007-963699...
41 Fueglistaler P, Wolff T, Guerke L, Stierli P, Eugster T. Endovascular stent graft for symptomatic mobile thrombus of the thoracic aorta. J Vasc Surg. 2005;42(4):781-3. http://dx.doi.org/10.1016/j.jvs.2005.05.054. PMid:16242568.
http://dx.doi.org/10.1016/j.jvs.2005.05....
42 Rancic Z, Pfammatter T, Lachat M, Frauenfelder T, Veith FJ, Mayer D. Floating aortic arch thrombus involving the supraaortic trunks: Successful treatment with supra-aortic debranching and antegrade endograft implantation. J Vasc Surg. 2009;50(5):1177-80. http://dx.doi.org/10.1016/j.jvs.2009.05.052. PMid:19628356.
http://dx.doi.org/10.1016/j.jvs.2009.05....
-4343 Jeyabalan G, Wallace JR, Chaer RA, Leers SA, Marone LK, Makaroun MS. Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions. J Vasc Surg. 2014;59(5):1256-64. http://dx.doi.org/10.1016/j.jvs.2013.11.068. PMid:24433783.
http://dx.doi.org/10.1016/j.jvs.2013.11....
Studies carried out to date do not report differences between use of stent grafts and uncoated stents.1111 Meyermann K, Trani J, Caputo FJ, Lombardi JV. Descending thoracic aortic mural thrombus presentation and treatment strategies. J Vasc Surg. 2017;66(3):931-6. http://dx.doi.org/10.1016/j.jvs.2017.05.109. PMid:28754361.
http://dx.doi.org/10.1016/j.jvs.2017.05....
,1414 Verma H, Meda N, Vora S, George RK, Tripathi RK. Contemporary management of symptomatic primary aortic mural thrombus. J Vasc Surg. 2014;60(6):1524-34. http://dx.doi.org/10.1016/j.jvs.2014.08.057. PMid:25256613.
http://dx.doi.org/10.1016/j.jvs.2014.08....
A meta-analysis of treatment strategies for patients with descending thoracic aortic mural thrombus evaluated 74 patients, 24 of whom were treated with anticoagulation, 19 with open surgery, and 29 with endovascular therapy. Of these, 6 patients who underwent open surgery and 9 patients who were managed with anticoagulation presented with recurrence. Eight of the recurrence patients were treated with endovascular approaches (4 from the open surgical group and 4 from the anticoagulation group). There were 4 deaths in the anticoagulation group and 2 deaths in the endovascular group. There were no recurrences in the endovascular group.1111 Meyermann K, Trani J, Caputo FJ, Lombardi JV. Descending thoracic aortic mural thrombus presentation and treatment strategies. J Vasc Surg. 2017;66(3):931-6. http://dx.doi.org/10.1016/j.jvs.2017.05.109. PMid:28754361.
http://dx.doi.org/10.1016/j.jvs.2017.05....
There are no meta-analyses comparing anticoagulation, open surgery, and endovascular approaches in the abdominal aorta.
There are a few reports of thoracic aortic thromboaspiration4444 Tsilimparis N, Spanos K, Debus ES, Rohlffs F, Kölbel T. Technical aspects of using the angiovac system for thrombus aspiration from the ascending aorta. J Endovasc Ther. 2018;25(5):550-3. http://dx.doi.org/10.1177/1526602818792568. PMid:30079784.
http://dx.doi.org/10.1177/15266028187925...
45 Brickwedel J, Kölbel T, Rohlffs F, Detter C, Reichenspurner H, Tsilimparis N. Thrombus aspiration from the ascending aorta using the angiovac device: a case report. Thorac Cardiovasc Surg. 2017;65(S 01):S1-110. http://dx.doi.org/10.1055/s-0037-1598891.
http://dx.doi.org/10.1055/s-0037-1598891...
-4646 Frisoli TM, So C-Y, Guruswamy JG, Chebl AB, Lee JC, Eng MH. Vacuuming in crowded dangerous spaces: aspiration of large ascending aortic thrombus. JACC Case Rep. 2020;2(12):1979-83. PMid:34317093. and abdominal aortic thromboaspiration3333 Murter CD, Sigdel A, Dwivedi AJ, Wayne EJ. Percutaneous thrombectomy of mural aortic thrombus using intravascular ultrasound guidance. J Vasc Surg Cases Innov Tech. 2019;5(4):472-6. http://dx.doi.org/10.1016/j.jvscit.2019.06.013. PMid:31763501.
http://dx.doi.org/10.1016/j.jvscit.2019....
with favorable outcomes. As studies advance, in the future this may become an option for treatment of abdominal aortic thrombus and may even be considered an option for treatment of mural aortic thrombus.
Endovascular therapy and open surgery seem to be the best options for treatment of abdominal aortic thrombus. Studies evaluating the thoracic aorta indicate that endovascular therapy is now the first line treatment. Despite this, endovascular therapy relies on adequate anatomy without prohibitive clot loading. Thus, in patients with favorable anatomy, endovascular therapy is probably the therapy of choice, while in those with unfavorable anatomy, open surgery is probably the best option. It is important to emphasize that anticoagulation alone can be attempted and, if unsuccessful, an endovascular or surgical approach can then be employed.
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How to cite: Martins APD, Bertolucci LH, Warpechowski RB, et al. Mobile thrombus of the abdominal aorta: a narrative review. J Vasc Bras. 2022;21:e20220028. https://doi.org/10.1590/1677-5449.202200282
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Financial support: None.
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The study was carried out at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil.
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Publication Dates
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Publication in this collection
09 Sept 2022 -
Date of issue
2022
History
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Received
24 Feb 2022 -
Accepted
27 June 2022