Name: 孫 x 燕 Gender: Female Age: 45 y/o Chart No.: 5138998 Date of Admission: 02/02/2007
Brief History Nausea, vomiting, diarrhea followed by abdominal distension on 96.1.30. Visited LMD and transferred to 中國附醫 PE: abdominal rebound pain, muscle guarding, hypoactive bowel sound. KUB: dilated bowel loops with gas content Abdominal CT: bowel obstruction and descending aorta thrombus noted.
． Segmental resection of jejunum and duodenum on 1/30 and 2/1 ． Aortic mass suspected tumor or thrombus 96/2/2 Transfer to NTUH ． SMA thrombectomy + third look + J-stomy on 02/05
Extubated on 2/8 Transfer to 9A on 2/10 Medical treatment Heparin infusion: 2/2-2/19 25000U/500ml IV titration Coumadin:2/7- 2/12 5mg 1/3# hs LMWH: 2/19-2/26 60mg q12h sc
PE General appearance: fair Cons: clear HEENT: Conj:pink, Sclera: anicteric, Neck: supple,LAP(-),JVE (-), Chest: symmetric, BS: clear Heart: RHB, no murmur, no heave, no thrill, Abdomen: Obese, soft,diffuse tenderness, no rebounding pain Ext.: freely movable, no edema, no cyanosis Hight: 162 BW:77.3-68.6 BMI:29.4
Past History HTN for 3 years, under medication control DM, heart disease, kidney disease, liver disease: denied No asthma or COPD Drinking or smoking: denied Drug: no long tern drug use ( Herb medicine, contraceptives), except anti-hypertensives Allergies: NKA OP history: nil
Autoimmune profile: ．中國 hospital: Homocysteine, protein C and protein S: within normal limit Antithrombin-III: mild decreased ． NTUH C3/C4:79.9/11.8 IgG/IgA/IgM: 619/175/39.2, C-ANCA: 0.4, P- ANCA: 1.0 ANA:1:40 – Anticardiolipin DVVT anti-β2 GP1 <15 U/ml （ moderate: 8-32 ） negative <20 units （ <26 ）
2/3 Serum protein electrophoresis(2/3): low albumin & beta globulins hypogammaglobulinemia (gamma globulins: 626 mg/dl; N: 700-1200 mg/dl). 2/23 Serum protein electrophoresis shows low albumin and increased alpha 1 & alpha 2 globulins (acute phase reaction), and marked polyclonal gammopathy (gamma globulins: 2024 mg/dl; N: 700-1200 mg/dl). 2/23 Random urine electrophoresis shows no protein. IFE Random urine IFE shows albumin and all fractions of globulins, but no Bence Jones protein.
B/C on 02/03: Acinetobacter baumannii （ both CVP and A-line ） Pathology: thrombus, IHC: no atypical cells are highlighted by cytokeratin. -------------------------------------------------------- Rheumatologist: DIC was suspected, not favored autoimmune Hematologist: complete work up was suggested ID man: not favored infection related thrombosis
Aortic Thrombosis Thrombosis of the aorta is generally secondary to atherosclerosis and aneurysms. Less common causes of aortic thrombosis are those related to trauma, inflammation and hypercoagulable states. Hypercoagulation of blood usually results in thrombosis in the venous circulation. Arterial thrombosis is rare; aortic thrombosis even rarer. Marcu, C. B. et al. CMAJ 2005;173:1027-1029
Arterial thrombosis is commonly related to an inherited and/or acquired hypercoagulable state. Inherited hypercoagulable state: deficiencies in one of the components in the coagulation– anticoagulation system Acquired hypercoagulable state: precipitating factors. Marcu, C. B. et al. CMAJ 2005;173:1027-1029
Chronic medication with glucocorticoids might have promoted hypercoagulability.
Non-atherosclerotic aorto- arterial thrombosis: A study of 30 cases at autopsy Vaideeswar P, Deshpande JR Department of Pathology (Cardiovascular Division), Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India J postgrade Med 2001;47;8-14
14 years retrospective study 30 autopsied cases of non-atherosclerotic and non- aneurysmal aorto-arterial thrombosis 23 males, 7 females Age: third to fourth decades Clinical features: acute abdomen or lower limb gangrene. Site: Abdominal aorta observed in 46.5% cases.
Treatment The ideal treatment of mobile aortic thrombi without atheromatosis has not been ascertained. Surgical removal, either by aortotomy with endarterectomy, thrombectomy or balloon embolectomy, and thrombolysis are the proposed therapies C. Sto¨llberger et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 880–882
Thrombolysis Anticoagulation Surgery Risk of repeat embolization that could result from partial lysis IV heparin followed by oral anticoagulant
Intravenous heparinization over 3 weeks with prothrombin time test (PTT) values between 80 and 100 s (baseline PTT 23.7 s), followed by oral anticoagulation with INR values between 3.0 and 4.0. TEE, performed after 4 weeks: regression of the thrombus to a length of 4 cm Cardiac MRI after another 6 weeks: complete resolution of the aortic thrombus. C. Sto¨llberger et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 880–882
If anticoagulation does not cause rapid resolution of a mobile thrombus, modern surgical methods combined with modern imaging by transoesophageal echocardiography allow for safe and controlled removal. KOLVEKAR ET AL FLOATING THROMBUS IN THE AORTA,Ann Thorac Surg 2001;72:927–9
Floating Thrombus in the Aorta Shyam K. Kolvekar, FRCS (CTh), Sanjay Chaubey, MBBS, and Richard Firmin, FRCS Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom Ann Thorac Surg 2001;72:925–7)
47-year-old man Presentation: transient ischemic episode in his left arm, followed by less severe episodes in his feet. Past history: no arrhythmia, ischemic heart disease, diabetes mellitus, or stroke.
Investigation Arch aortogram: normal Further TEE: a large free-floating thrombus in the descending aorta. The thrombophilia screen: normal
Ann Thorac Surg 2001;72:925–7 It appeared to be attached at the site of the ductus ligament in the descending aorta and extended down to the diaphragm.
Management Anticoagulation therapy initially MRI reassessment 2 weeks later: no change Because of the risk of further distal embolism and lack of progress, it was thought necessary to remove the clot surgically.
Ann Thorac Surg 2001;72:925–7 A large thrombus measuring more than 15 cm was removed from the descending aorta.
Pathology: Organized thrombus without evidence of malignancy Discharged 2 weeks later with Warfarin.
Comment Ligamentum ateriosus as a source for thrombus formation: local endothelial abnormality was the origin of the problem. Transoesophageal echocardiogram has become an important investigation of not only the heart but also the descending aorta
Primary Aortic Mural Thrombus: Presentation and Treatment Annals of Vascular Surgery Vol. 13, No. 1, 1999
CasePresentationSiteImageTreatmentoutcome 50,FLower back pain radiation to legs and abdomen Renal infarction TEE, MRI: a 10-cm* 15–20 mm floating, highly mobile thrombus in the descending aorta. IV heparin followed by oral anticoagulant the thrombus resolved after 10 weeks and no recurrence occurred over the next 30 months. 24,M periumbilical and right costovertebral pain accompanied by nausea and vomiting Right kidney and SMA infarction TEE: mobile thrombus 1.5 ∞ 2 cm in the descending thoracic aorta near the origin of the left subclavian Artery 1.Embolectomy with patch angioplasty 2. IV heparin followed by oral anticoagulant resolution of the aortic thrombus seen on TEE at 8 weeks ’ follow- Up 47,M transient ischemic episode of left arm and feet TEE: a large free- floating thrombus attached at the site of the ductus ligament in the descending aorta and extended down to the diaphragm 1.anticoagulation therapy, failed 2. Surgical removal 3. Oral anticoagulant ?
Back to our patient Large aortic thrombus Etiology: ATIII deficiency? Current treatment: s/p SMA thrombectomy anticoagulants F/U CECT: no resolution of thrombosis Further plan: surgical removal? adjust anticoagulant dose?
Reference 1.Primary Aortic Mural Thrombus: Presentation and Treatment Annals of Vascular Surgery Vol. 13, No. 1, 1999 2.Marcu, C. B. et al. CMAJ 2005;173:1027-1029 3.J postgrade Med 2001;47;8-14 Non-atherosclerotic aorto-arterial thrombosis: A study of 30 cases at autopsy 4.C. Sto¨llberger et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 880–882 5.KOLVEKAR ET AL FLOATING THROMBUS IN THE AORTA,Ann Thorac Surg 2001;72:927–9 6.CardiovascularSurgeq, Vol. 4, No. 6, pp.846-847, 1996 7.Extensive Aortic Thromboembolism—Zhang et al Arch Pathol Lab Med—Vol 129, February 2005
Extensive Aortic Thromboembolism Due to Acquired Hypercoagulable State An Autopsy Case Report Ling Zhang, MD; Sandra Hollensead, MD; Joseph C. Parker, Jr, MD