(Circulation. 1998;97:1421-1422.)
© 1998 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Systemic Embolism From a Large Ascending Aortic Thrombus
Robert N. Doughty, MD, MRCP, FRACP;
David A. Haydock, MBChB, FRACS;
John Wattie, MBChB, FRACR;
James T. Stewart, MB, MD, MRCP;
; Mark W.I. Webster, MBChB, FRACP
From the Departments of Cardiology (R.N.D., J.T.S., M.W.I.W.),
Cardiothoracic Surgery (D.A.H.), and Vascular Radiology (J.W.), Green Lane
Hospital, Auckland, New Zealand.
Correspondence to Dr R.N. Doughty, Department of Medicine, University of Auckland School of Medicine, Private Bag 92019, Auckland, New Zealand.
The ascending aorta is increasingly recognized as a
source of thromboembolism in patients with stroke. This case describes
a 53-year-old man with diffuse atherosclerosis and a
large ascending aortic thrombus who presented with pain and pallor of
sudden onset in his right hand. Past history included myocardial
infarction 11 years earlier, hypertension, and
hypercholesterolemia. Before his myocardial
infarction, he had smoked 60 to 100 cigarettes per day and more
recently was smoking 20 to 30 per day. A left above-knee amputation had
been performed 3 years earlier for severe peripheral
vascular disease, and 3 months before this presentation he
suffered a stroke with left-sided weakness. Physical examination
revealed cooled and mottled fingers with heavy tar staining and
multiple splinter hemorrhages on the nails of the right hand
(Fig 1
). Right radial and brachial pulses
were palpable, the right ulnar and left femoral arteries were not
palpable, and the right femoral pulse was reduced. There was a moderate
residual left-sided weakness. Examination was otherwise
unremarkable.
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Figure 1. Patient's right hand 1 week after embolic
event, showing multiple splinter hemorrhages and marked tar
staining of fingers.
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Digital subtraction angiography of the right arm showed occlusions in
the mid-ulnar and distal radial arteries. Aortography showed an
elongated filling defect in the ascending aorta (Fig 2). Transesophageal
echocardiography confirmed a mass arising from the
ascending aorta above the aortic valve (Fig 3). At operation, a tongue-shaped mass
originating 1 cm above the right and noncoronary commissures of
the aortic valve and extending to the origin of the left carotid artery
(Figs 4 and 5) was
removed. Macroscopically, the aortic wall
appeared normal, without severe atheroma. This was
confirmed by histology, which also demonstrated that the mass was a
thrombus. The patient made an uneventful recovery.
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Figure 2. Digital subtraction angiogram of ascending
thoracic aorta showing a large filling defect extending from proximal
ascending aorta to aortic arch.
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Figure 3. Multiplane transesophageal
echocardiogram depicting mass attached to aortic wall just above level
of sinus of Valsalva. Ao indicates aorta; Th, thrombus.
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Figure 4. Intraoperative photograph showing distal end
of mass as it is withdrawn through aortic incision.
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Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
