Case Report
A 47-year-old male presented with weakness in his left arm upon
awakening. Mild fine motor impairment and mild paresthesia were
observed. Magnetic resonance imaging (MRI) showed cerebral infarction in
the left frontal and parietal lobe. Contrast-enhanced computed
tomography (CT) revealed a well-defined pedunculated cord-like object in
the aortic arch extending from the lesser curvature of the ascending
aorta into one-third the length of the left common carotid artery
(Figure 1 ). CT also showed mural thrombus and stenosis of the
abdominal aorta and obstruction of the right common iliac artery and the
left deep femoral artery. Transesophageal echocardiography revealed a
mobile pedunculated object suggestive of a thrombus arising from the
ascending aorta and extending to the left common carotid artery
(Figure 2 ). Hematologic investigations, including lipid
profile, hematocrit, platelet count, protein C, protein S, and
antiphospholipid antibody, were unremarkable.
Because the object was considered high risk for additional embolic
events, the patient underwent emergent surgery. The operation was
performed through a median sternotomy. Cardiopulmonary bypass was
established by cannulation of the right femoral artery and right atrium.
In order to prevent embolism of the thrombus, we undertook direct
cannulation into the left common carotid artery distal to the thrombus.
The left common carotid artery was exposed by a separate left cervical
incision (parallel to the left sternocleidomastoid muscle). While
cooling the patient to 28°C, the left common carotid artery was incised
and directly cannulated with a balloon-tipped catheter for selective
antegrade cerebral perfusion (SACP) via the left cervical incision. The
proximal side of the left common carotid artery was clamped. Under deep
hypothermic circulatory arrest, the ascending aorta was opened through a
longitudinal incision. The cord-like object suggestive of a thrombus was
attached to the lesser curvature of the ascending aorta and extended
into the left common carotid artery. The thrombus was easily removed
from the aortic wall. The brachiocephalic artery was cannulated with a
balloon-tipped catheter for SACP. Thrombectomy with a 5 Fr Fogarty
catheter was performed into the left common carotid artery, but no
thrombus remained. The aortotomy was closed with 4-0 polypropylene
continuous suture.
Histopathological examination revealed that the object was a thrombus
(Figure 3 ). The postoperative course was uneventful. No
additional embolism was observed. The patient was discharged 9 days
after surgery. The patient was treated with oral aspirin, clopidogrel,
and warfarin postoperatively. No recurrence of the thrombus was observed
at the one-year follow-up.