Abstract Introduction Aortic mural or occlusive thrombus in the absence of concomitant aortic aneurysm is a clinically uncommon condition with limited knowledge on best management strategies. Clot burden and characteristic features alter morbidity and mortality to some degree, but the presence of an aortic thrombus alone is enough to estimate a mortality risk above twenty percent. Thus, there remains the need for comparative review of current diagnostic approaches for a condition without distinct guidelines. Our case allows us to survey the sole or conjoined use of the following therapeutic strategies which are often employed in management of blood clots: use of anticoagulation versus systemic thrombolytics versus open or minimally invasive thrombectomy. Description We present the case of a 62-year-old female with medical history of hypertension, atrial fibrillation/flutter and rheumatic mitral valve disease status post mitral valve replacement reportedly compliant with warfarin therapy who presented for evaluation of sudden motor and sensory loss below the level of the umbilicus with urinary incontinence, preceded by one day of sustained back pain and lower extremity tingling. Physical exam was remarkable for hypertension, tachyarrhythmia, and lower extremities cool to touch with 0/5 motor and sensory function. Initial contrast enhanced computed tomography revealed infrarenal aortic occlusion, right renal artery occlusion, superior mesenteric artery thrombosis, and inferior mesenteric artery occlusion. A multidisciplinary team decision (involving vascular surgery and interventional radiology) was made to administer Tenecteplase in an effort to aid reperfusion. In the next hours, hemodynamic compromise was evident, prompting an open thrombectomy approach with continued systemic anticoagulation. Ultimately, the patient expired within 24 hours of hospital admission. Discussion In this case, extensive occlusion of major vessels despite reported adherence to therapeutic warfarin posed a major therapeutic challenge. Future literature may aim to define risk stratification models and comparative outcomes between any combination of anticoagulation, systemic versus targeted thrombolysis, and open versus endovascular strategies with the goal of establishing management guidelines for optimal therapy. As always, maintaining a broad differential remains paramount especially when considering the patient with sudden onset paraplegia wherein aortic thrombosis may mimic spinal cord pathology. The question of how best to approach acute aortic occlusion and its critical complications remains. This abstract is funded by: None
Ozkan et al. (Fri,) studied this question.