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Vascular » Aortoiliac
Mural thrombus in the aorta
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Presentation A 95 year old male presented with right calf pain and shortness of breath. He was diagnosed with pulmonary embolism and acute right deep vein thrombosis. His past medical history is significant for coronary artery disease, renal insufficiency and two episodes of cerebrovascular accident. An ultrasound of the abdomen was performed.
Caption: Sagittal image of the aorta.
Description: The aorta shows the presence of echogenic material within its lumen.
Caption: Sagittal color Doppler scan.
Description: The part of the lumen which showed the echogenic material shows no color flow within it. This is suggestive of thrombosis.
Caption: Transverse color Doppler image.
Description: Color Doppler image of the aorta just above the region of thrombus shows a completely patent lumen. The maximal aortic diameter is 2.1 cm.
Caption: Transverse color Doppler scan.
Description: Color Doppler scan in the region of the thrombus shows a small patent lumen anteriorly. The patent lumen measured approximately 5 mm.
Caption: Transverse color Doppler view.
Description: Color Doppler image of the aorta just below the area of the thrombus demonstrating reconstitution of the lumen.
Differential Diagnosis Mural thrombus in the distal aorta.
Final Diagnosis Mural thrombus in the distal aorta.
Discussion Primary aortic non-occlusive thrombus is a rare entity and not commonly encountered in routine practice. These thrombi may be associated with atherosclerotic plaques or may evolve de novo in the aorta. In  patients with established atherosclerotic disease upon which the thrombus is superimposed, this disease may pursue a more aggressive course. In patients where thrombus is the only finding, an underlying hypercoaguable state has been postulated predisposing to thrombus formation. There are also reports of de novo aortic thrombosis in patients with protein C and protein S deficiency and in neonates too.

Earlier, it was believed that a primary thrombus developed due to the paradoxical effects of heparin therapy. However, a study by Williams, et al in 1981 identified certain risk factors that predispose a patient to aortic thrombosis and these included heart disease, recent thrombophlebitis, heparin therapy, abdominal atherosclerosis and postoperative status. Most of these patients had serious medical problems and at least two of the ‘risk factors’. The patient demonstrated here also had multiple medical problems and two of the risk factors mentioned above.

Aortic thrombus can be a potential source for peripheral emboli and hence needs to be recognized and treated in such a clinical setting. A morphologically normal aorta with echogenic material in its lumen and varying degrees of aortic occlusion is identified. The entire length of aorta must be scanned in order to completely evaluate the extent of disease. Ultrasound with color Doppler is diagnostic and is also useful for monitoring these patients in cases where the aorta is well visualized. Surgical thrombectomy, thrombolysis and systemic anticoagulation are the therapeutic options. In many patients treatment with anticoagulants has resulted in complete resolution of the thrombus.

Thus if a patient presents with symptoms of embolic disease and a non cardiac source is suspected, a thorough evaluation of the aorta is indicated.

Case References 1. Hahn T, et al. Primary aortic mural thrombus: Presentation and treatment. Ann Vasc Surg 1999; 13: 52-9.
2. Williams GM, et al. Mural thrombus of the aorta: an important, frequently neglected cause of large peripheral emboli. Ann Surg. 1981 Dec; 194(6):737-44.
3. Bowdish ME, et al. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002 Oct; 36(4):713-9.
4. Lorelli DR, et al. Aortic mural thrombus embolization: an unusual presentation of essential thrombocytosis. Ann Vasc Surg. 2002 May; 16(3):375-9.
5. Gagliardi JM, et al. Mural thrombus of the aorta. Ann Vasc Surg. 1988 Jul; 2(3):201-4.
6. Rossi PJ, et al. Paravisceral aortic thrombus as a source of peripheral embolization--report of three cases and review of the literature. J Vasc Surg. 2002 Oct; 36(4):839-43.
7. Machleder HI, et al. Aortic mural thrombus: an occult source of arterial thromboembolism. J Vasc Surg. 1986 Nov; 4(5):473-8.
Follow Up This patient was started on heparin anticoagulation therapy and observed for development of any further symptoms.
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