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.