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Thoracic Aortic Mobile Thrombus (TAMT)

Thoracic Aortic Mobile Thrombus (TAMT): Is There a Role for Early Surgical Intervention? PAGNI S, TRIVEDI JR, DWIVEDI AJ, GANZEL BL, WILLIAMS ML, MASCIO CE, ROSS C, SLATER AD DIVISION OF THORACIC AND CARDIOVASCULAR SURGERY, UNIVERSITY OF LOUISVILLE, LOUISVILLE KY, USA.

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Thoracic Aortic Mobile Thrombus (TAMT)

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  1. Thoracic Aortic Mobile Thrombus (TAMT):Is There a Role for Early Surgical Intervention?PAGNI S, TRIVEDI JR, DWIVEDI AJ, GANZEL BL, WILLIAMS ML,MASCIO CE, ROSS C, SLATER ADDIVISION OF THORACIC AND CARDIOVASCULAR SURGERY,UNIVERSITY OF LOUISVILLE, LOUISVILLE KY, USA

  2. Thoracic Aortic Mobile Thrombus (TAMT) 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

  3. Thoracic Aortic Mobile Thrombus (TAMT) OBJECTIVES • To describe the clinical presentation, treatment and outcome of 13 patients with TAMT • To define a treatment strategy for patients with TAMT

  4. Thoracic Aortic Mobile Thrombus (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

  5. Thoracic Aortic Mobile Thrombus (TAMT) PATIENT CHARACTERISTICS

  6. Thoracic Aortic Mobile Thrombus (TAMT) Pathology • 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

  7. Thoracic Aortic Mobile Thrombus (TAMT) Clinical Scenario 46 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

  8. Thoracic Aortic Mobile Thrombus (TAMT) Surgical Procedures • Thoracic aortic thrombectomies n=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 • 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

  9. Thoracic Aortic Mobile Thrombus (TAMT) Clinical Outcomes • 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 • 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

  10. Thoracic Aortic Mobile Thrombus (TAMT) 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

  11. Thoracic Aortic Mobile Thrombus (TAMT) 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

  12. Thoracic Aortic Mobile Thrombus (TAMT) 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

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