Discussion
The pathophysiology of a fluttering cord-like thrombus in the aortic arch is unclear. Thrombophilic states are infrequently observed. Laperche et al. reported that, among 23 patients with mobile thrombi of the aortic arch, only 4 cases presented with thrombophilic states [1]. In our case, the patient did not have a thrombophilic state, but the aorta was atherosclerotic. Mural thrombus and stenosis of the abdominal aorta and obstruction of the right common iliac artery and the left deep femoral artery were observed.
Evidence related to management of thrombus in the aorta is very limited. A few cases reported successful management with anticoagulant therapy [2] [3]. Medical treatment (heparinization), endovascular stenting [4], and surgery have been proposed, but no comparative data are available. In our case, because MRI revealed cerebral infarction and the fluttering cord-like thrombus extended to the left common carotid artery, the thrombus was considered high risk for additional cerebral infarction and we performed thrombectomy.
Traditionally, aortic thrombus have been removed under hypothermic cardiac arrest either by distal ascending aortic cannulation [5] or femoral cannulation [6]. Kalangos et al. reported the successful removal of a thrombus in the proximal ascending aorta without hypothermic circulatory arrest [7]. We performed thrombectomy under hypothermic circulatory arrest and selective cerebral perfusion using cardiopulmonary bypass through the femoral artery and the right atrium. In our case, a fluttering cord-like thrombus attached to the aortic arch extended to the left common carotid artery. To prevent distal embolization of the thrombus, the left common carotid artery was directly cannulated with a balloon-tipped catheter for SACP via the left cervical incision and the proximal side of the left common carotid artery was clamped. After thrombectomy under hypothermic cardiac arrest, the brachiocephalic artery was cannulated with a selective cerebral perfusion cannula. This technique is considered useful when a thrombus in the aortic arch extends to the neck arteries.