TEVAR for primary aortic mural thrombus: when and how?

Abstract

INTRODUCTION: Primary aortic mural thrombus (PAMT) is a rare cause of peripheral embolization that has been associated with hypercoagulable states. Anticoagulation is usually the first-line strategy, but has been associated with a significant risk of recurrent embolization.
CASE-REPORT: A 51-year-old male patient with a history of right lung carcinoma underwent a follow-up computed tomography angiography (CTA) scan that revealed an incidental thrombus in the descending thoracic aorta. Conservative treatment with full-dose enoxaparin was initiated. A week later, the patient presented symptoms of pain and paraesthesia of the left lower limb. A new CTA scan revealed extension of the thrombus, with two pedunculated floating thrombi in the descending thoracic aorta. Thus, a diagnosis of left acute limb ischemia due to embolization originating from a PAMT was assumed. Thoracic Endovascular Aortic Repair (TEVAR) was performed to control the embolic source and prevent new events. To prevent visceral embolization during the TEVAR procedure, low-pressure angioplasty balloons were positioned in the visceral arteries. The thrombi were excluded using a Valiant® endoprosthesis 30x150mm. Subsequently, a left transfemoral thrombectomy was performed, achieving normal blood flow to the foot. No adverse events occurred in the postoperative period. The patient was discharged on aspirin and rivaroxaban and continues to be followed in outpatient care, remaining asymptomatic to date.
CONCLUSIONS: Although rare, PAMT should be suspected as a possible embolic source, especially in patients with hypercoagulable states such as neoplasms. Our case highlights that in cases of recurrence embolization despite anticoagulation, the use of TEVAR to exclude aortic thrombi is effective in preventing additional embolization.