Acute
arterial occlusion of the aorta
(Portuguese
PDF version)
Coordinated
by Dr. João Luiz Sandri
João Luiz Sandri1, 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
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.
Figure
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).
Figure
2 - Ecocardiografia transesofágica.
Figure
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).
Figure
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.
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.
