![Page 1: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/1.jpg)
Case Discussion
Intern 薛婉儀 / VS 韓吟宜
![Page 2: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/2.jpg)
• Name: 孫 x燕• Gender: Female• Age: 45 y/o• Chart No.: 5138998• Date of Admission: 02/02/2007
![Page 3: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/3.jpg)
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.
![Page 4: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/4.jpg)
. 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
![Page 5: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/5.jpg)
• 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
![Page 6: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/6.jpg)
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
![Page 7: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/7.jpg)
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
![Page 8: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/8.jpg)
Family History
Hepatic tumor
![Page 9: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/9.jpg)
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+
![Page 10: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/10.jpg)
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 )
![Page 11: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/11.jpg)
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.
![Page 12: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/12.jpg)
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
![Page 13: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/13.jpg)
• 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
![Page 14: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/14.jpg)
ImageAbdominal CT 96/1/30
![Page 15: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/15.jpg)
![Page 16: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/16.jpg)
![Page 17: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/17.jpg)
![Page 18: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/18.jpg)
![Page 19: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/19.jpg)
![Page 20: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/20.jpg)
![Page 21: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/21.jpg)
![Page 22: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/22.jpg)
Abdominal CT 96/2/13
![Page 23: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/23.jpg)
![Page 24: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/24.jpg)
![Page 25: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/25.jpg)
![Page 26: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/26.jpg)
![Page 27: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/27.jpg)
![Page 28: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/28.jpg)
Discussion
![Page 29: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/29.jpg)
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
![Page 30: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/30.jpg)
Copyright ©2005 CMA Media Inc. or its licensors
Marcu, C. B. et al. CMAJ 2005;173:1027-1029
![Page 31: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/31.jpg)
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
![Page 32: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/32.jpg)
Marcu, C. B. et al. CMAJ 2005;173:1027-1029
![Page 33: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/33.jpg)
Copyright ©2005 CMA Media Inc. or its licensors
Marcu, C. B. et al. CMAJ 2005;173:1027-1029
![Page 34: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/34.jpg)
• Chronic medication with glucocorticoids might have promoted hypercoagulability.
![Page 35: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/35.jpg)
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
![Page 36: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/36.jpg)
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.
![Page 37: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/37.jpg)
![Page 38: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/38.jpg)
![Page 39: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/39.jpg)
![Page 40: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/40.jpg)
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
![Page 41: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/41.jpg)
Thrombolysis
Anticoagulation
Surgery
Risk of repeat embolization that could result from partial lysis
IV heparin followed by oral anticoagulant
![Page 42: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/42.jpg)
• 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
![Page 43: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/43.jpg)
• 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
![Page 44: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/44.jpg)
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)
![Page 45: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/45.jpg)
• 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.
![Page 46: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/46.jpg)
Investigation
• Arch aortogram: normal• Further TEE: a large free-floating thrombus in the
descending aorta . • The thrombophilia screen: normal
![Page 47: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/47.jpg)
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.
![Page 48: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/48.jpg)
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.
![Page 49: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/49.jpg)
Ann Thorac Surg 2001;72:925–7
A large thrombus measuring more than 15 cm was removed from the descending aorta.
![Page 50: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/50.jpg)
• Pathology: Organized thrombus without evidence of malignancy
• Discharged 2 weeks later with Warfarin.
![Page 51: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/51.jpg)
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
![Page 52: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/52.jpg)
Primary Aortic Mural Thrombus: Presentation and TreatmentAnnals of Vascular Surgery Vol. 13, No. 1, 1999
![Page 53: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/53.jpg)
Case 3
![Page 54: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/54.jpg)
Case 6
![Page 55: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/55.jpg)
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
?
![Page 56: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/56.jpg)
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?
![Page 57: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/57.jpg)
Thank you for attention!
![Page 58: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/58.jpg)
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
![Page 59: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/59.jpg)
Extensive Aortic Thromboembolism Due to AcquiredHypercoagulable StateAn Autopsy Case Report
Ling Zhang, MD; Sandra Hollensead, MD; Joseph C. Parker, Jr, MD
![Page 60: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/60.jpg)
Extensive Aortic Thromboembolism—Zhang et al
![Page 61: 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](https://reader035.vdocuments.pub/reader035/viewer/2022081417/56649cc45503460f9498d77a/html5/thumbnails/61.jpg)