Systemic Embolism From a Large Ascending Aortic Thrombus
The ascending aorta is increasingly recognized as a source of thromboembolism in patients with stroke. This case describes a 53-year-old man with diffuse atherosclerosis and a large ascending aortic thrombus who presented with pain and pallor of sudden onset in his right hand. Past history included myocardial infarction 11 years earlier, hypertension, and hypercholesterolemia. Before his myocardial infarction, he had smoked 60 to 100 cigarettes per day and more recently was smoking 20 to 30 per day. A left above-knee amputation had been performed 3 years earlier for severe peripheral vascular disease, and 3 months before this presentation he suffered a stroke with left-sided weakness. Physical examination revealed cooled and mottled fingers with heavy tar staining and multiple splinter hemorrhages on the nails of the right hand (Fig 1⇓). Right radial and brachial pulses were palpable, the right ulnar and left femoral arteries were not palpable, and the right femoral pulse was reduced. There was a moderate residual left-sided weakness. Examination was otherwise unremarkable.
Digital subtraction angiography of the right arm showed occlusions in the mid-ulnar and distal radial arteries. Aortography showed an elongated filling defect in the ascending aorta (Fig 2⇓). Transesophageal echocardiography confirmed a mass arising from the ascending aorta above the aortic valve (Fig 3⇓). At operation, a tongue-shaped mass originating 1 cm above the right and noncoronary commissures of the aortic valve and extending to the origin of the left carotid artery (Figs 4⇓ and 5⇓) was removed. Macroscopically, the aortic wall appeared normal, without severe atheroma. This was confirmed by histology, which also demonstrated that the mass was a thrombus. The patient made an uneventful recovery.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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