title: Protruding aortic arch thrombus: treatment with minimally invasive surgical approach.
abstract: BACKGROUND
  Protruding aortic arch thrombus is associated clinically with life-threatening emboli. Definitive treatment for aortic arch thrombus removal has demanded complicated vascular surgical procedures, with high morbidity and mortality.
  
  
  RESULTS
  Transesophageal echocardiography (TEE) enabled diagnosis of a protruding thrombus at the aortic arch in 5 patients, and a simultaneous lesion in the descending aorta in 1 patient. Four patients had visceral emboli, coinciding with peripheral emboli in 2 patients, and the fifth patient had peripheral and cerebral emboli. One patient had had ischemic stroke and femoral emboli a few months previously. Mean patient age was 51 years. None had clinical evidence of coronary or peripheral atherosclerotic occlusive disease. Risk factors included hypertension (n = 2), smoking (n = 4), and preexisting thrombophilia (n = 4). Five patients underwent TEE-guided aortic balloon thrombectomy from the arch with a 34-mm occluding balloon catheter. One patient also underwent balloon thrombectomy from the descending aorta with a 14F Foley catheter. Access into the aorta was obtained through the iliac artery (n = 4) during laparotomy because of visceral ischemia or through the transfemoral approach (n = 2). Previous procedures included superior mesenteric embolectomy (n = 3), segmental bowel resection (n = 1), splenectomy (n = 1), and peripheral arterial embolectomy n = 3). Real-time intraoperative TEE enabled visualization of the protruding thrombus and assisted with maneuvering of the balloon catheter. At completion peripheral thrombectomy thrombus material was retrieved in 4 patients. Postoperatively there were no clinically proved new procedure-related visceral emboli, and all patients received anticoagulant therapy thereafter. Follow-up TEE within 2 weeks and up to 7 years revealed no recurrent aortic arch thrombus.
  
  
  CONCLUSIONS
  TEE-guided aortic balloon thrombectomy used in 6 procedures was effectively completed without visceral or peripheral ischemic complications. It enabled removal of the life-threatening source of emboli from the proximal aorta, thereby averting the need of major aortic surgery.
authors.affiliation: Department of Vascular Surgery and the Gottesdiener Vascular Biology Laboratory, Sheba Medical Center Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel. jschneid@netvision.net.il
authors.forename: Jacob
authors.initials: J
authors.lastname: Schneiderman
authors.forename: Micha S
authors.initials: MS
authors.lastname: Feinberg
authors.forename: Ehud
authors.initials: E
authors.lastname: Schwammenthal
authors.forename: Alex
authors.initials: A
authors.lastname: Tenenbaum
authors.forename: Alex
authors.initials: A
authors.lastname: Garniak
authors.forename: Binyamina
authors.initials: B
authors.lastname: Morag
authors.forename: Raphael
authors.initials: R
authors.lastname: Walden
authors.forename: Eitan
authors.initials: E
authors.lastname: Heldenberg
authors.forename: Hana
authors.initials: H
authors.lastname: Fenigstein
authors.forename: Raphael
authors.initials: R
authors.lastname: Adar
mesh_terms: D001015:Aortic Arch Syndromes / Q000000981:diagnostic imaging* / Q000601:surgery*; D001018:Aortic Diseases / Q000000981:diagnostic imaging / Q000601:surgery; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D017131:Thrombectomy; D013927:Thrombosis / Q000000981:diagnostic imaging* / Q000601:surgery*; D016896:Treatment Outcome