case discussion intern 薛婉儀 / vs 韓吟宜. name: 孫 x 燕 gender: female age: 45 y/o chart...

Case Discussion

Intern 薛婉儀 / VS 韓吟宜

• Name: 孫 x燕• Gender: Female• Age: 45 y/o• Chart No.: 5138998• Date of Admission: 02/02/2007

Brief History• Nausea, vomiting, diarrhea followed by abdominal dis

tension on 96.1.30.

Visited LMD and transferred to 中國附醫

PE: abdominal rebound pain , muscle guarding, hypoactive bowel sound.

KUB: dilated bowel loops with gas content

Abdominal CT: bowel obstruction and descending aorta thrombus noted.

． Segmental resection of jejunum and duodenum on 1/30 and 2/1

． Aortic mass suspected tumor or thrombus

96/2/2 Transfer to NTUH

． SMA thrombectomy + third look + J-stomy on 02/05

• Extubated on 2/8

• Transfer to 9A on 2/10

• Medical treatment

Heparin infusion: 2/2-2/19 25000U/500ml IV titration

Coumadin:2/7- 2/12 5mg 1/3# hs

LMWH: 2/19-2/26 60mg q12h sc

PE• General appearance: fair• Cons: clear • HEENT: Conj:pink, Sclera: anicteric,

Neck: supple,LAP(-),JVE (-),• Chest: symmetric, BS: clear • Heart: RHB, no murmur, no heave, no thrill, • Abdomen: Obese, soft ,diffuse tenderness, no

rebounding pain• Ext.: freely movable, no edema, no cyanosis• Hight: 162 BW:77.3-68.6 BMI:29.4

Past History

• HTN for 3 years, under medication control• DM, heart disease, kidney disease, liver disease:

denied• No asthma or COPD• Drinking or smoking: denied• Drug: no long tern drug use ( Herb medicine, cont

raceptives), except anti-hypertensives• Allergies: NKA• OP history: nil

Family History

Hepatic tumor

Lab Data 

WBC Seg Eos CRP Hb Plat

2/2 30410 87.1 0.5 19.91 9.0 282K

2/9 17720 86.5 1.5 13.94 6.9 580K

  Bil T/D AST ALT BUN Cre

2/2 0.99   375 12.0 0.8

2/9 3.2/1.95 56 66 13.3 0.6

  PT aPTT 2/2

18.1 37.1 2/9 17.6 59.8

U/A: WBC: 0-2, RBC:3-5,

Protein: 1+

Autoimmune profile:．中國 hospital:

Homocysteine, protein C and protein S: within normal limit

Antithrombin-III: mild decreased

． NTUH

C3/C4:79.9/11.8 IgG/IgA/IgM: 619/175/39.2,

C-ANCA: 0.4, P- ANCA: 1.0

ANA:1:40 –

Anticardiolipin DVVT anti-β2 GP1

<15 U/ml （ moderate: 8-32 ） negative <20 units （ <2

6 ）

2/3 Serum protein electrophoresis(2/3): low albumin & beta globulins hypogammaglobulinemia (gamma globulins: 626 mg/dl; N: 700-1200 mg/dl).

2/23 Serum protein electrophoresis shows low albumin and

increased alpha 1 & alpha 2 globulins (acute phase reaction), and marked polyclonal gammopathy (gamma globulins: 2024 mg/dl; N: 700-1200 mg/dl).

2/23 Random urine electrophoresis shows no protein. IFE Random urine IFE shows albumin and all fractions of globulins, but no Bence Jones protein.

Couagulative profile:

Fibrinogen: 825 PTT: 36 （ under Heparin titration and coumadin ） PLT: 421 K/μL

FDP/3P/D-dimer: 25.9/ 4+/ 1115

Endocrine

ACTH, Cortisol, aldosterone, urine VMA: 13.844 （ 1-7 mg/24h ） , catecholamine: pending

• B/C on 02/03: Acinetobacter baumannii （ both CVP and A-line ）

• Pathology: thrombus, IHC: no atypical cells are highlighted by cytokeratin.

--------------------------------------------------------• Rheumatologist: DIC was suspected, not favored aut

oimmune

• Hematologist: complete work up was suggested

• ID man: not favored infection related thrombosis

ImageAbdominal CT 96/1/30

Abdominal CT 96/2/13

Discussion

Aortic Thrombosis

• Thrombosis of the aorta is generally secondary to atherosclerosis and aneurysms.

• Less common causes of aortic thrombosis are those related to trauma, inflammation and hypercoagulable states.

• Hypercoagulation of blood usually results in thrombosis in the venous circulation. Arterial thrombosis is rare; aortic thrombosis even rarer.

Marcu, C. B. et al. CMAJ 2005;173:1027-1029

Copyright ©2005 CMA Media Inc. or its licensors

Marcu, C. B. et al. CMAJ 2005;173:1027-1029

Arterial thrombosis is commonly related to an inherited

and/or acquired hypercoagulable state.

• Inherited hypercoagulable state:

deficiencies in one of the components in the coagulatio

n– anticoagulation system

• Acquired hypercoagulable state: precipitating factors .

Marcu, C. B. et al. CMAJ 2005;173:1027-1029

Marcu, C. B. et al. CMAJ 2005;173:1027-1029

Copyright ©2005 CMA Media Inc. or its licensors

Marcu, C. B. et al. CMAJ 2005;173:1027-1029

• Chronic medication with glucocorticoids might have promoted hypercoagulability.

Non-atherosclerotic aorto-arterial thrombosis: A study of 30 cases at autopsy

Vaideeswar P, Deshpande JR Department of Pathology (Cardiovascular Division), Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., I

ndia

J postgrade Med 2001;47;8-14

14 years retrospective study• 30 autopsied cases of non-atherosclerotic and non-

aneurysmal aorto-arterial thrombosis • 23 males, 7 females• Age: third to fourth decades • Clinical features: acute abdomen or lower limb ga

ngrene. • Site: Abdominal aorta observed in 46.5% cases.

Treatment

• The ideal treatment of mobile aortic thrombi without atheromatosis has not been ascertained.

• Surgical removal, either by aortotomy with endarterectomy, thrombectomy or balloon embolectomy, and thrombolysis are the proposed therapies

C. Sto¨llberger et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 880–882

Thrombolysis

Anticoagulation

Surgery

Risk of repeat embolization that could result from partial lysis

IV heparin followed by oral anticoagulant

• Intravenous heparinization over 3 weeks with prothrombin time test (PTT) values between 80 and 100 s (baseline PTT 23.7 s), followed by oral anticoagulation with INR values between 3.0 and 4.0.

• TEE, performed after 4 weeks: regression of the thrombus to a length of 4 cm

• Cardiac MRI after another 6 weeks: complete resolution of the aortic thrombus.

C. Sto¨llberger et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 880–882

• If anticoagulation does not cause rapid resolu

tion of a mobile thrombus, modern surgical m

ethods combined with modern imaging by tra

nsoesophageal echocardiography allow for s

afe and controlled removal.

KOLVEKAR ET AL FLOATING THROMBUS IN THE AORTA ,Ann Thorac Surg 2001;72:927–9

Floating Thrombus in the AortaShyam K. Kolvekar, FRCS (CTh),

Sanjay Chaubey, MBBS, and Richard Firmin, FRCSDepartment of Cardiac Surgery, Glenfield Hospital, Leicester,

United Kingdom

Ann Thorac Surg 2001;72:925–7)

• 47-year-old man

• Presentation: transient ischemic episode in his left arm, followed by less severe episodes in his feet.

• Past history: no arrhythmia, ischemic heart disease, diabetes mellitus, or stroke.

Investigation

• Arch aortogram: normal• Further TEE: a large free-floating thrombus in the

descending aorta . • The thrombophilia screen: normal

Ann Thorac Surg 2001;72:925–7

It appeared to be attached at the site of the ductus ligament in the descending aorta and extended down to the diaphragm.

Management

• Anticoagulation therapy initially

• MRI reassessment 2 weeks later: no change

• Because of the risk of further distal embolism and lack of progress, it was thought necessary to remove the clot surgically.

Ann Thorac Surg 2001;72:925–7

A large thrombus measuring more than 15 cm was removed from the descending aorta.

• Pathology: Organized thrombus without evidence of malignancy

• Discharged 2 weeks later with Warfarin.

Comment

• Ligamentum ateriosus as a source for thrombus formation: local endothelial abnormality was the origin of the problem.

• Transoesophageal echocardiogram has become an important investigation of not only the heart but also the descending aorta

Primary Aortic Mural Thrombus: Presentation and TreatmentAnnals of Vascular Surgery Vol. 13, No. 1, 1999

Case 3

Case 6

Case Presentation Site Image Treatment outcome

50,F Lower back pain radiation to legs and abdomen

Renal infarction

TEE, MRI: a 10-cm* 15–20 mm floating, highly mobile thrombus in the descending aorta .

IV heparin followed by oral anticoagulant

the thrombus resolved after 10 weeks and no recurrence occurred over the next 30 months.

24,M periumbilical and right costovertebralpain accompanied by nausea andvomiting

Right kidney and SMA infarction

TEE: mobile thrombus 1.5 ∞2 cm in the descending thoracicaorta near the origin of the left subclavianArtery

1.Embolectomy with patch angioplasty2. IV heparin followed by oral anticoagulant

resolution of the aorticthrombus seen on TEE at 8 weeks’follow-Up

47,M transient ischemic episode of left arm and feet

TEE: a large free-floating thrombus attached at the site of the ductus ligament in the descending aorta and extended down to the diaphragm

1.anticoagulation therapy, failed2. Surgical removal3. Oral anticoagulant

?

Back to our patient

• Large aortic thrombus• Etiology: ATIII deficiency?• Current treatment: s/p SMA thrombectomy

anticoagulants• F/U CECT: no resolution of thrombosis• Further plan: surgical removal?

adjust anticoagulant dose?

Thank you for attention!

Reference1. Primary Aortic Mural Thrombus: Presentation and Treatment

Annals of Vascular Surgery Vol. 13, No. 1, 1999

2. Marcu, C. B. et al. CMAJ 2005;173:1027-1029

3. J postgrade Med 2001;47;8-14 Non-atherosclerotic aorto-arterial thrombosis: A study of 30 cases at autopsy

4. C. Sto¨llberger et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 880–882

5. KOLVEKAR ET AL FLOATING THROMBUS IN THE AORTA ,Ann Thorac Surg 2001;72:927–9

6. CardiovascularSurgeq, Vol. 4, No. 6, pp.846-847, 1996

7. Extensive Aortic Thromboembolism—Zhang et al Arch Pathol Lab Med—Vol 129, February 2005

Extensive Aortic Thromboembolism Due to AcquiredHypercoagulable StateAn Autopsy Case Report

Ling Zhang, MD; Sandra Hollensead, MD; Joseph C. Parker, Jr, MD

Extensive Aortic Thromboembolism—Zhang et al