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Subclinical Thrombosis of the Ascending Aorta: A Possible Paraneoplastic Syndrome

2009; Elsevier BV; Volume: 88; Issue: 1 Linguagem: Inglês

10.1016/j.athoracsur.2008.11.020

1552-6259

Víctor X. Mosquera, J.J Cuenca, Pablo Pazos, José María Herrera, Mohammad Mohammad, Alberto Juffé,

Cardiac tumors and thrombi

Thrombosis of the ascending aorta is a rare, potentially lethal complication. We report the case of a 56-year-old woman with a massive but subclinic thrombosis of the ascending aorta after two cycles of chemotherapy due to an epidermoid lung carcinoma stage T3 N2 M0. An emergent aortic thrombectomy was performed under deep hypothermic circulatory arrest. This thrombotic event occurred in an arterial vessel with high laminar flow, which is extremely uncommon and did not present any clinical manifestation. Thrombosis of the ascending aorta is a rare, potentially lethal complication. We report the case of a 56-year-old woman with a massive but subclinic thrombosis of the ascending aorta after two cycles of chemotherapy due to an epidermoid lung carcinoma stage T3 N2 M0. An emergent aortic thrombectomy was performed under deep hypothermic circulatory arrest. This thrombotic event occurred in an arterial vessel with high laminar flow, which is extremely uncommon and did not present any clinical manifestation. Thrombosis of the aortic arch and descending aorta are not an uncommon cause of peripheral embolism. However, thrombosis of the ascending aorta is a rare, potentially lethal complication. A 56-year-old woman was referred to our institution due to the radiologic finding of a huge thrombus in the ascending aorta (Fig 1A) in a control thoraco-abdominal contrast-enhanced computed tomographic scan (CT). One month earlier, the patient had been diagnosed of an epidermoid lung carcinoma stage T3 N2 M0. She had already received two cycles of chemotherapy (cisplatin/etoposide). There was another control CT scan performed 24 days earlier that did not reveal any vascular alteration neither in the aorta nor in another vascular location. However, the new CT scan showed a thrombus that occupied more than 60% of the lumen of the ascending aorta. The patient was asymptomatic, and on examination, the presence of severe cachexia and hypoventilation of the right lung upper lobe were the only remarkable findings. Laboratory test results were unremarkable. A coagulation test was normal. Closer examination of the CT scan also revealed the presence of several silent embolic infarctions in the spleen and in the left kidney. A transesophageal echocardiogram confirmed the presence of a pedicled mass of 4 cm length (Figs 1B and 1C) in the ascending aorta, just 2 cm above the sinotubular junction. Due to the high risk of new embolic events, an emergent cardiac surgery was indicated. Cardiopulmonary bypass was established after cannulation of the femoral artery and the right atrium. Under deep hypothermic circulatory arrest, an inverted "T" aortotomy was performed, and a large thrombotic mass was identified and totally removed (Fig 1D). The aortic wall was carefully inspected without finding any evidence of a pathologic process at the aortic site of insertion of the thrombus. The pathologic study revealed that the whole mass (Fig 2) was constituted by coagulated hematic material with a mild central infiltration of polymorphonuclear neutrophils. There was evidence neither of malignancy nor of a bacterial or fungal origin. Long-term, oral anticoagulant therapy with Sintrom (acenocumarol; Novartis Farma S.p.A., Origgio, Italy) was started after the operation. The patient recovered completely and was discharged from the hospital 5 days later. A third chemotherapy cycle was completed after the surgery and a new CT scan revealed reduction of the tumoral mass and no signs of intravascular complications. The patient was admitted for surgical treatment of the lung cancer 45 days after the cardiac intervention. A right upper lobectomy and lymphadenectomy was performed. Six months later the patient remained asymptomatic at the outpatient clinic follow-up.Fig 2Picture of the explanted mass with 4 cm of longitudinal diameter and 2.3 cm of axial diameter.View Large Image Figure ViewerDownload (PPT) Thrombosis of the aortic arch and descending aorta are not an uncommon cause of peripheral embolism [1Choukroun E.M. Labrousse L.M. Madonna F.P. Deville C. Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 cases.Ann Vasc Surg. 2002; 16: 714-722Abstract Full Text PDF PubMed Scopus (113) Google Scholar]. Notwithstanding, aortic thrombosis usually occurs in patients with an atherosclerotic diseased aorta. A localized thrombus involving the ascending aorta or arch rarely, or both, occurs in the absence of an underlying cause, such as chest trauma, atherosclerosis, a hypercoagulable state, or instrumentation [2Geha A.S. El-Zein C. Massad M.G. et al.Surgery for aortic arch thrombosis.Thorac Cardiovasc Surg. 2004; 52: 187-190Crossref PubMed Scopus (13) Google Scholar]. The importance of this case lays on the lack of any radiologic or anatomic sign of atherosclerosis in the aortic wall. Therefore, the most likeable cause of aortic thrombosis in this case is a hypercoagulable state as a paraneoplastic syndrome caused by the primary lung cancer, which may reach an incidence of 2% of cases [3Naschitz J.E. Yeshurun D. Eldar S. Lev L.M. Diagnosis of cancer-associated vascular disorders.Cancer. 1996; 77: 1759-1767Crossref PubMed Scopus (86) Google Scholar, 4Shlebak A.A. Smith D.B. Incidence of objectively diagnosed thromboembolic disease in cancer patients undergoing cytotoxic chemotherapy and/or hormonal therapy.Cancer Chemother Pharmacol. 1997; 39: 462-466Crossref PubMed Scopus (27) Google Scholar]. Moreover, this thrombotic event occurred in an arterial vessel with high laminar flow, which is extremely uncommon and did not present any clinical manifestation. In spite of the fact that an important percentage of cases later on need surgery, the first choice of treatment in case of aortic thrombosis is usually a high-dose anticoagulation with intravenous heparin [2Geha A.S. El-Zein C. Massad M.G. et al.Surgery for aortic arch thrombosis.Thorac Cardiovasc Surg. 2004; 52: 187-190Crossref PubMed Scopus (13) Google Scholar]. Nevertheless, in this case, the transesophageal echocardiography provided us invaluable information about the fact of being a pedicled mass and its size, both of which are factors related to the probability of embolism [5Schwartzbard A. Freedberg R.S. Kronzon I. The value of repeat transesophageal echocardiography in the evaluation of embolism from the aorta.J Am Soc Echocardiogr. 2000; 13: 1124-1126Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. In this case, in spite of the compromised, long-term prognosis of the patient, we considered it appropriate to offer her a surgical intervention due to the high probability of a non-lethal stroke and its potentially catastrophic complications. Therefore, we strongly believe that in this uncommon but potentially lethal pathology, an aggressive surgical treatment is indicated rather than a more conservative approach, especially when the morphologic features of the thrombus suggest a high-risk of embolism.