Peripheral Vascular Surgery Society
|
|
Peripheral Vascular Surgery Society |
|
|
|
#22 IDIOPATHIC PEDUNCULATED MURAL THROMBUS OF NON-ANEURYSMAL INFRARENAL AORTA PRESENTING WITH POPLITEAL EMBOLIZATION: 2 CASES TREATED WITH LYTIC THERAPY
Matthew J. Dougherty, MD and Keith D. Calligaro, MD
Pennsylvania Hospital Philadelphia, PA
We have observed the finding of a large, pedunculated aortic thrombus associated with only trivial atherosclerotic plaque in several patients presenting with peripheral, large-vessel embolism. We report herein two patients treated successfully with a combination of catheter directed lytic therapy and anticoagulation.
Case 1. A 71-year-old healthy woman with no history of or risk factors for atherosclerotic disease presented with abrupt onset, left calf claudication and intermittent rest pain, and clinical findings suggesting popliteal artery occlusion. Arteriography demonstrated a 2-cm pedunculated thrombus in the infrarenal aorta and a 1-cm popliteal artery embolus, with no significant atherosclerotic changes elsewhere. An infusion catheter was placed in the popliteal embolus and urokinase therapy successfully lysed the embolus, while the proximal clot remained. The patient initially declined surgical removal of the aortic lesion and was anticoagulated with heparin, and on follow-up ultrasound and MRA 5 days later there was no aortic abnormality. She was treated with Coumadin for 6 months and aspirin thereafter and has remained free of abnormality on duplex surveillance through 4 years.
Case 2. A 59 year old female smoker with no other atherosclerotic risk factors presented 6 weeks after sigmoid colectomy for colon cancer with a 3 day history of intermittent left foot rest pain. She had been hospitalized for chemotherapy-related dehydration and granulocytopenic colitis one week earlier. Arteriography showed a 1.5-cm teardrop shaped filling defect in the infrarenal aorta, and popliteal embolus. Urokinase therapy was directed at the aortic thrombus with complete resolution within 12 hours, however further embolization was noted at the popliteal and tibial level, necessitating extended catheter-directed therapy. Though successful, she developed massive lower GI bleeding presumed secondary to the recent colitis, which was successfully controlled with Pitressin infusion. No further anticoagulation was utilized. Surgery was not necessary, and no aortic or peripheral abnormalities were present on duplex at 2 years follow-up.
These cases illustrate the development of extensive, unstable thrombus on the luminal surface of otherwise undiseased aortae in patients without manifestations of atherosclerosis. Hypercoagulability profiles were normal. In contradistinction to spontaneous atheroembolism, lytic therapy can effectively restore arterial continuity, and spontaneous resolution of the aortic thrombus may be observed with anticoagulation, obviating the need for surgery.
Return to Master Program
Last updated January 10, 1999