Acute arterial occlusion of the aorta

(Portuguese PDF version)

Coordinated by Dr. João Luiz Sandri
João Luiz Sandri
1, Fábio Luiz Costa Pereira2

1. Assistant Professor, Clinical Surgery, Escola Superior de Ciências, Santa Casa de Misericórdia de Vitória. Vascular Surgeon, Hospital Metropolitano.
2. Vascular Surgeon, Hospital Metropolitano.

Correspondence:
Dr. João Luiz Sandri
Av. Nossa Senhora da Penha, 714/1006-8
CEP 29055-130 - Vitória - ES
E-mail: jlsandri@escelsa.com.br

J Vasc Br 2003;2(2):161-3


Part II - DIAGNOSIS

MANAGEMENT

The patient received epidural anesthesia and was being submitted to embolectomy, without satisfactory results.

Given these circumstances, acute dissection of the aorta was initially considered, although the patient's medical history was not typical and no chest pain had been reported. However, as the patient suffered from severe hypertension, it was necessary to immediately confirm dissection through a good-quality exam. The surgery was interrupted, the arteriotomy and the surgical incision were sutured, and the patient was taken to the hemodynamics laboratory for angiographic investigation of the abdominal aorta and iliac arteries.

The patient was then submitted to digital subtraction angiography of the aorta and iliac arteries (Figure 1), which revealed thrombi from the infrarenal aorta to the iliac arteries.

click hereFigure 1 - Angiografia digital da aorta.

The patient was submitted to surgery again, but this time, a retroperitoneal approach to the aorta and left common iliac artery was used. The arteriotomy of the left common iliac artery showed canoe-shaped thromboembolic material, suggesting a thrombus detached from the proximal aortic wall. This time, there was good flow after Fogarty catheter6 embolectomy and after removal of a 12-cm long, orange red, consistent thrombus, which clearly showed a noncardiac source of embolism. The right common femoral artery was also examined, showing good flow through the right iliac segment. The distal arterial tree was free of distal thrombi after the use of Fogarty catheters4.

The patient showed favorable outcome, and the source of embolism was further investigated.

The transesophageal echocardiography showed a floating mural thrombus in the aortic arch (Figure 2), and the computed tomography angiography revealed a large floating proximal thrombus attached to the aortic arch (Figure 3).

click hereFigure 2 - Ecocardiografia transesofágica.

click hereFigure 3 - Angiotomografia.

After eight days, the patient was submitted to thoracic aortic surgery, with circulatory arrest and extracorporeal circulation for removal of the thrombus from the aortic mural thrombus. A small lesion on the aortic wall was observed after the remnants of the thrombus were resected (Figure 4).

click hereFigure 4 - Trombo aórtico mural retirado na cirurgia da aorta torácica.

The pathoanatomical analysis of the removed thrombi indicated that they were not recent and consisted of fibrin, erythrocytes and neutrophils, but this analysis was inconclusive.

The patient had an uneventful recovery. In the postoperative period, he was maintained with low molecular weight heparin and was discharged after being prescribed oral anticoagulant therapy for later investigation of thrombophilic factors.

COMMENTS

The difficulty in establishing good arterial flow during arterial embolectomy, especially through the left side, where most dissections of the aorta show dissection up to the iliac artery, led us to think of aortic dissection.1 It is quite common to make the diagnosis of this disorder when the embolectomy catheter does not succeed in removing the thrombi or in reestablishing good jet flow in a femoral artery.

Although most arterial emboli originate in the heart, about 20% form at other sites or are idiopathic.2,3

Since the emboli showed morphological characteristics that suggest extracardiac origin, the patient was submitted to transesophageal echocardiography (TEE)4 and to computed tomography angiography of the thoracic aorta. TEE showed a large floating thrombus in the aorta, which was confirmed by computed tomography angiography. These exams show details of aortic pathology, confirming or ruling out the existence of intracavitary thrombi.5 After the diagnosis of floating aortic mural thrombus was confirmed, the patient was electively prepared for the removal of the thrombus from the aorta, with circulatory arrest and extracorporeal circulation, in order to remove the remnants of the thrombus, which imposed risk of reembolization, with high morbidity to the patient.6,7

The patient was discharged without any intercurrent disease, maintained on oral anticoagulant therapy, and investigated for coagulopathies and hematological causes.

It should be underscored that when treating arterial embolism, the vascular surgeon is treating a complication of an underlying heart disease or not, quite often unknown to the patient and which should be certainly investigated.

REFERENCES

1. Rabny N, Giles J, Walters H. Aortic dissection presenting as acute leg ischemia. Clinical Radiol 1990;42:116-7.

2. van Bellen B, Zorn WGW. Obstrução arterial aguda. In: Brito CJ. Cirurgia Vascular. 1ª ed. Rio de Janeiro: Livraria e Editora Revinter; 2002. p. 687-704.

3. Lastória S, Maffei FHA. Oclusões Arteriais Agudas. In: Maffei FHA, Lastória S, Yoshida WB, Rollo HA. Doenças Vasculares Periféricas. 3ª ed. Rio de Janeiro: Medsi Editora Médica e Científica Ltda.; 2002. p. 969-997.

4. Davila-Roman VG, Westerhausen D, Hopkins WE, Sicard GA, Barzalai B. Transesophageal echocardiography in the detection of cardiovascular sources of peripheral vascular embolism. Ann Vasc Surg 1995;115:432-7.

5. Nienaber CA, Von Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993;328:1-9.

6. Culliford AT, Tunick PA, Katz ES, Kronzon I, Galloway AC, Ribakove GH. Initial experience with removal of protruding atheroma from the aortic arch: diagnosis by transesophageal echo, operative technique and follow-up. J Am Coll Cardiol 1993;21:342.

7. Kalangos A, Baldovinos A, Vuille C, Montessuit M, Faidutti B. Floating thrombus in the ascending aorta: a rare cause of peripheral emboli. J Vasc Surg 1997;26:150-4.

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J Vasc Br - Official Publication of the Brazilian Society of Angiology and Vascular Surgery