Primary aortic mural thrombus

Case report and disccusion

20220224 高雄榮民總醫院
PGY 陳建維 徐奕菱 王可柔 潘喬云
Supervisor 吳銘庭主任
 CASE 1
GENERAL DATA

● Name:許x睿
● Patient number: 18483346
● Gender: male
● Age: 44 y/o
● Admission date: 2021-06-05
● Discharge date: 2021-06-24
 CASE 1
CHIEF COMPLAINT

RUQ abdominal pain for 2 months,

exaggerating over LUQ abdomen since 2 days ago
 CASE 1
PRESENT ILLNESS

2021-06-04　輔英H.
　　　　　　　abdominal CT：spleen and right kidney infarction

2021-06-05　referred to our ER
　　　　　　　Lab:
 CASE 1
PRESENT ILLNESS

2021-06-04　輔英H.
　　　　　　　abdominal CT：spleen and right kidney infarction

2021-06-05　referred to our ER
　　　　　　　Admission for further survey
 CASE 1
2021-06-09 CTA, Chest-Aorta, PE
 CASE 1
2021-06-09 CTA, Chest-Aorta, PE
 CASE 1
2021-06-09 CTA, Chest-Aorta, PE
 CASE 1
Impression

● Suspect endovascular angiosarcoma of ascending aorta with

distal tumor embolism
 CASE 1
Surgical pathology 2021-06-18

● - Aorta, ascending, biopsy --- Acute and chronic inflammation

● - Mixed acute and chronic inflammatory infiltrate in the adventitia and
tunica media including some plasma cells.
●

● - Although the result of immunostain of treponema is negative, the syphilis

aortitis could not be totally excluded.
 CASE 1
Impression

● Syphilis, tertiary, complicated with aortitis and mild ascending aortic

aneurysm, with thrombosis formation, s/p median sternotomy, aortotmy
with thrombus removal and biopsy of aortic wall on 2021/06/18

● Spleen and right kidney infarction, s/p bone marrow biopsy on

2021/06/09, without evidence of malignancy, suspected syphilitic aortitis
related thromboembolism
 CASE 2
GENERAL DATA

● Name:邱x雯
● Patient number: 19206667
● Gender: female
● Age: 46 y/o
● Admission date: 2021-11-06
● Discharge date: 2021-11-12
 CASE 2
CHIEF COMPLAINT

Sudden onset abdominal pain with dullness for one day.

 CASE 2
PRESENT ILLNESS

2021-11-04　安南H.
　　　　　　　abdominal CT：
　　　　　　　- irregular thrombi over abdominal aorta
　　　　　　　- multifocal arterial liver and spleen infarctions
　　　　　　　- suspect bilateral ovarian cancer

2021-11-04　referred to our ER
 CASE 2
PRESENT ILLNESS

2021-11-04　referred to our ER
　　　　　　　Lab:
 CASE 2
2021-11-05 CT whole abdomen with contrast
 CASE 2
2021-11-05 CT whole abdomen with contrast
 CASE 2
2021-11-05 CT whole abdomen with contrast
 CASE 2
2021-11-05 CT whole abdomen with contrast
 CASE 2
Impression

-Primary aortic mural thrombus (PAMT) (16x9x4 mm) at

abdominal aorta, with poor left hepatic perfusion and
splenic infarction

-Bilateral ovarian cancer with diffuse peritoneal

carcinomatosis
Tentative AJCC 8th edition image staging: T3cN0M0
Image challenge

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Differential diagnosis

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Aortic Artheroscelrosis

● irregular thickening of the intima ≥2 mm

○ Complex: thickness >4 mm, ulceration, or mobility
○ Risk factors for embolization
● TEE
● CT

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Aortic Artheroscelrosis
● Prevelence:
○ Aortic plaque in any location was present in 43.7%(TEE exmination)
○ Complex plaque: 7.6%
● Risk of stroke:
○ Severe aortic plaque in stroke patients (14% to 21%)
○ in 1 year for patients with severe plaque in aortic arch on TEE is 10% to 12%
● Treatment:
○ Medications: aspirin, statin, diet control
○ Quitting smoking
○ Aortic arch atherectomy
● Mortality:
○ as high as 20 percent within three years with complex plaque
■ 20 percent of the deaths are attributed to stroke
■ additional 7 percent to other embolic events
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Minimal aortic injury
● mild form of blunt traumatic aortic injury which are limited to the aortic intima
and are recognized more frequently due to the use of high-resolution vascular
imaging in trauma.

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Minimal aortic injury—CT findings
Direct signs

● intimal irregularity or flap under 10 mm in size with no external wall contour abnormality
○ most common imaging appearance (~80%)
○ rounded, triangular or focal thin membrane-like linear filling defects
● small intramural hematoma (~10%)without outer contour abnormality of the aortic wall
○ if a non contrast series has been performed, a IMH may demonstrate slight crescenteric
hyperdensity
● small pseudoaneurysm usually in the anteromedial aorta at the isthmus

Indirect sign

● more commonly seen with significant aortic injury rather than MAI
● periaortic hematoma, despite being included in the original definitive as excluding MAI, a study has
found a large proportion of MAI can coexisting periaortic hematoma
● mediastinal hematoma
● intraluminal aortic thrombus
● associated injuries
○ sternal fractures, upper rib fractures, scapular injuries, upper thoracic vertebral fractures
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Minimal aortic injury
● Treatment
○ medical management
○ may resolve spontaneously
○ surgical intervention (TEVAR)
● Suggestion
○ follow up CTA at 48-72 hours
○ repeat CTA at one month
● Prognosis
○ most resolve spontaneously
○ distal emboli to the kidneys or
spleen in 17% of patients in one
cohort study

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Angiosarcoma
【CT findings】
1. Volume-occupying and bulky limiting the
luminal diameter.
2. Polypoid (intraluminal) and are attached with a
stalk to the aortic wall.
3. Hyper enhanced on arterial phase due to their
vascularity that makes them separable from
atherosclerotic plaques.
4. Sometimes mimic protrusive vegetation or
nodular soft tissue component.
Kordzadeh A, Askari A, Navi A, Patel S, Parsa AD, Charalabopoulos A. Primary angiosarcoma of aorta: A systematic review. Vascular. 2021 Jul
8:17085381211026491. doi: 10.1177/17085381211026491. Epub ahead of print. PMID: 34238080.

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Angiosarcoma
● Primary malignant tumours of the aorta (PMTAs)
○ PA arising from endothelial cell of the aorta or cardiac accounts for 4.7% of all angiosarcomas.
○ Amplification of PDGFRA & EGFR due to over expression of MDM2 oncogene (p53).
● Clinical manifestation
○ Location: Abdominal aorta (45%), thoracic aorta (37%), aortic arch (13%) and ascending
○ Age: Mostly diagnosis at 5th or 6th decade of life.
○ Lower limb claudication (25%), abdominal pain or back pain (22%), weight loss (10%),
renovascular hypertension (8%) and acute upper or lower limb ischaemia (6%).
● Treatment
○ No consensus (Biopsy to surgical resection w/o adjuvant chemo- and/or radiotherapy)
● Prognosis
○ Mostly have distant metastasis with poor long-term survival. (Overall survival rate: 210 days)
Fatima J, Duncan AA, Maleszewski JJ, Kalra M, Oderich GS, Gloviczki P, Suri RM, Bower TC. Primary angiosarcoma of the aorta, great vessels, and the heart. J Vasc Surg. 2013 Mar;57(3):756-64. doi: 10.1016/j.jvs.2012.09.023. Epub 2013 Jan 9.
PMID: 23312835.
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Syphilitic aortitis
【Case report】
● 64-year-old male with abdominal pain due to
allergic colitis
● CT Coronal view:
irregular noncalcified thrombus in the distal
infrarenal segment of the vessel significantly
narrowing the effective lumen of the abdominal
aorta
● An incidental finding without evidence of
embolic disease

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Syphilitic aortitis
● Etiology
○ Treponema pallidum is an invasive bacteria with the ability to readily
cross-endothelial barriers through its ability to interact with, and activate platelets.
○ Aortitis: invasion of the aortic wall and the resultant endarteritis of the vasa
vasorum and necrosis of the connective tissue and elastic fibers of the aortic
media.
● Clinical manifestation
○ Location: Ascending aorta (50%); aortic arch (35%); descending aorta (15%).
○ Age: Most commonly in the fourth to fifth decades of life.
○ Aortic aneurysms (most commmon), aortic regurgitation, coronary ostial stenosis,
Thrombosis of the aorta (rare)
● Treatment
○ Abx with penicillin, Aspirin and statin therapy
 60 y/o male, no CV disease or risk
Dyspnea, Lower limb ischemia
Aortic thrombosis in COVID-19 s/p Angio, died from severe renal failure

CT angiography (sagittal) showing A coronal total occlusive thrombus (Cross-section) at level of the renal
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thrombus and narrowed aortic lumen. in the infrarenal abdominal aorta. artery.
Yarımoglu R, Yarımoglu S, Tastan H, Erkengel HI. Acute infrarenal abdominal aortic occlusion in a patient with COVID-19. Ann Saudi Med. 2021 Nov-Dec;41(6):392-395. doi:
10.5144/0256-4947.2021.392. Epub 2021 Dec 2. PMID: 34873931; PMCID: PMC8650592.
Aortic thrombosis in COVID-19
● Etiology
○ Excessive inflammation, platelet activation, endothelial dysfunction, and
stasis.
● Clinical menifestation
○ Location: Abdominal aortic occlusion (2.7 to 5.0 cases per 1 million) person-years.
● Treatment
○ Low molecular weight heparin (LMWH) (decrease mortality)
● Prognosis
○ Prediction of the events was not possible; Demographic factors, laboratory data,
and severity of COVID-19 did not appear to be related to arterial events.
○ Oxley et al.: 5 cases of large-vessel stroke in patients younger than 50 y/o.
○ The median time from onset at the clinic consistent with coronavirus infection to the
development of limb ischemia was 19 (11-23) days.
○ Mortality rates: 25% to 75% and morbidity rates between 30% and 74%.

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 Cause Location Symptoms CT findings Treatment Prognosis

PAMT Idiopathic descending aorta thromboembolic thrombus attached to Anticoagulant Uncertained

events aortic wall Stent
Surgery

Artheroma Artherosclerosis Abdominal aorta stroke calcified Statin 1 year stroke rate
atherosclerosis Aspirin in aortic arch
change, plaque Diet control severe plaque:
10~12%

MAI Trauma aortic isthmus Chest pain intimal irregularity or BP control Resolve
automobile thoracic aorta Difficulty breathing flap under 10 mm in spontaneously
collisions(81%) size with no external
wall contour
abnormality

Malignancy Chemical exposure abdominal aorta (45%) 好發50-60歲成年人 Volume-occupying, Surgery 5-year survival
p53 thoracic aorta (37%) Chemotherpy (?)
-Agnsiosarcoma non-specific bulky, polypoid rates: 8%
Stewart–Treves aortic arch (13%)
weight loss, fatigue, (intraluminal), Radiotherapy (?)
ascending aorta (4%)
syndrome
iliac aortic bifurcation (1%) fever and pain protrusive vegetation,
(abdominal or back) hyper vascular without
atherosclerotic lesions

Syphilitic aortitis Activate Ascending aorta (50%); 好發 40-50 歲成年人 irregular Penicillin Stroke
platelets aortic arch (35%); calcified/non-calcified Aspirin Rare incidence
descending aorta (15%) thrombus Statin

Hypercoagulopathy COVID-19 Abdominal aorta Stroke Occlusive thrombus LMWH Mortality: 25%-75%
Ischemia limb Morbidity: 30%-74%.
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Primary aortic mural thrombus

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Image challenge

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