Logo American Journal of Case Reports

Call: 1.631.629.4328
Mon-Fri 10 am - 2 pm EST

Contact Us

Logo American Journal of Case Reports Logo American Journal of Case Reports Logo American Journal of Case Reports

03 April 2023: Articles  China (mainland)

Acute Occlusion of the Abdominal Aorta Associated with Left Ventricular Thrombus: A Case Report

Challenging differential diagnosis, Rare disease

Xuan Zhang12ABCEF, Hao Zou3ABF, Yuan Rong12ADEG*

DOI: 10.12659/AJCR.939095

Am J Case Rep 2023; 24:e939095

0 Comments

Abstract

BACKGROUND: Acute aortic occlusion (AAO) is a rare emergency with high mortality. The typical clinical presentation is the sudden appearance of pain, paralysis, sensory disturbances, and mottling of the lower extremities. The etiology of AAO can be broadly classified into 3 categories: in situ thrombosis, arterial embolism, and occlusion of grafts. AAO is a rare consequence of myocardial infarction in the era of anticoagulation therapy, as part of the management of acute coronary syndrome (ACS).

CASE REPORT: We report the case of a 65-year-old woman who presented with acute lower extremity pain and weakness after a myocardial infarction 2 weeks earlier. She was on standardized antiplatelet therapy, a high blood D-dimer level was found during a visit to the Emergency Department, a left ventricular mural thrombus was detected using bedside ultrasound, and computed tomography angiography revealed thrombotic occlusion of the abdominal aorta. AAO disease was diagnosed, but the patient refused further treatment and died after 7 days of follow-up.

CONCLUSIONS: In recent years, anticoagulation has become part of the standard of care for patients with myocardial infarction or atrial fibrillation, which has led to a lower incidence of arterial embolism leading to AAO than in situ thrombosis. Depending on the type of occlusion, there are also differences in the surgical approach. A computed tomography angiography of the abdomen should be performed on all patients in whom AAO cannot be ruled out. Timely diagnosis and prompt surgical intervention are essential to preventing mortality.

Keywords: Acute Aortic Occlusion, Aortic Saddle Embolism, Cardiac Thrombus, Female, Humans, Aged, Aorta, Abdominal, Thrombosis, Embolism, Myocardial Infarction, Arterial Occlusive Diseases, Abdomen

Background

Acute aortic occlusion (AAO) is a rare but potentially devastating emergency. Grip et al confirmed an annual incidence of AAO of 3.8 per 1 million people, with a mean age of onset of 69.7 years [1]. The mortality in patients with AAO remains high, despite advances in cardiology, anesthesia, and critical care in the last 20 years [2]. AAO occlusion often manifests as acute lower extremity pain, paralysis, pulselessness, sensory disturbances, and skin pallor, which can have life-threatening consequences in severe cases [3–6].

There are multiple etiologies for AAO, and the most common etiologies are embolic events from the heart and complete thrombosis of the distal aorta [7]. The major sources of cardiac emboli are atrial fibrillation, severe cardiac dysfunction, and cardiac arrhythmias [7]. Acute myocardial infarction (AMI) is another source of large emboli, but research has shown that the incidence of embolic AAO after AMI is extremely uncommon [2]. Here, we report a case of acute AAO in a patient who had previously experienced a left ventricular aneurysm after AMI.

Case Report

A 65-year-old woman presented to our Emergency Department with the acute onset of bilateral lower extremity pain and weakness. The pain had appeared abruptly the previous day when the patient was sitting. Bloating and appetite loss were also present. Two weeks earlier, she had an AMI and underwent percutaneous coronary intervention, with 2 bare metal stents. She developed a complication of ventricular aneurysm after the AMI, during which she was treated regularly with dual antiplatelet therapy. There was no history of smoking or alcohol consumption, and no other chronic illness.

The patient’s vital signs were normal. The cardiopulmonary examination was unremarkable, except for the soft heart sounds. The abdominal examination revealed mottling of the abdominal wall below the umbilical level (Figure 1A). With significant pitting edema, the left leg was mottled and chilly and had no dorsal pedis artery pulse (Figure 1B).

Blood analysis showed an N-terminal pro b-type natriuretic peptide level of >35 000 ng/L (reference range, 300–900 ng/L), creatine kinase-myocardial band level of 94 U/L (reference range, 0–25 U/L), and a D-dimer level of 36 900 µg/L (reference range, 80–500 µg/L). A biochemical examination showed an albumin level of 17.2 g/L (reference range, 40–55 g/L), blood glucose level of 9.61 mmol/L (reference range, 3.9–6.1 mmol/L), and normal renal function. Blood routine examinations were un-remarkable, except for a white blood cell count of 10.3×109/L (reference range, 4.0–10.0×109/L).

The electrocardiogram showed an old MI (Figure 2). Then, we performed aortic computed tomography angiography (CTA), which revealed a partial filling defect in the abdominal aorta at the L3 level and no significant contrast development in the abdominal aorta or bilateral iliac vessels (Figure 3). Bedside echocardiography confirmed a mural left ventricular thrombus and an enlarged left atrium with reduced left ventricular systolic function (biplane Simpson method), with an ejection fraction of 9% (Figure 4). The ultrasound showed blood flow in the lower extremities was stagnant in the femoral arteries, superficial femoral arteries, and deep femoral arteries.

We considered the diagnosis was abdominal aortic thromboembolism. The patient and her family were fully informed of the severity of the disease and the poor prognosis. Because of financial constraints, the patient and family refused all subsequent tests and treatments by written signature. After 7 days of follow-up, the patient died without receiving any treatment.

Discussion

As previously mentioned, the etiology of AAO is broadly divided into 3 categories. A study on AAO published in 2019 concluded that the most common cause of AAO is still arterial thrombosis in situ, with embolization being the second most common cause. Although the proportion of patients with graft/stent/stent-graft occlusion has increased over this 20-year period, this may be related to the increased use of endovascular therapy [1,8].

Aortic saddle embolism is the most common form of embolism leading to AAO. The embolus terminates and straddles the aortic bifurcation, producing the distal aorta occlusion. With the recognition of the importance of and increased use of anticoagulation therapy, the occurrence of ventricular thrombus has declined. Thompson et al [8] confirmed that the incidence of AAO following AMI is <1%. However, because of an aging population, the overall prevalence of coronary artery diseases remains higher, and it is essential to take preventive actions to avoid serious cardiovascular events [2].

Recently, case reports also showed that AAO is associated with SARS-CoV-2 infection [9–13]. It remains unknown whether the incidence of AAO differs between patients with and without COVID-19 until specific data statistics are available. However, there are still individual cases that suggest this connection should not be ignored. Yarmoglu et al report a case of an AAO patient with no risk factors for thromboembolism, and the authors argue that the case of AAO could be attributed to SARSCoV-2 infection [9].

The typical clinical presentation includes the sudden onset of bilateral leg pain, neurologic deficits, and lower extremity mottling, which can alert clinicians to AAO. CTA can demonstrate the exact location and extent of the occlusion, which makes accurately diagnosing AAO not very difficult. However, uncommon presentations (anuria, abdominal pain, back pain, or chest pain) can cause a delay in diagnosis and treatment [14].

AAO is rare compared with other arterial embolic diseases, and the patient is usually on standard antiplatelet therapy, which makes it difficult to make a correct diagnosis immediately. Because the patient in our case refused further examination and treatment, there was no proof of a definite embolic source. Thrombosis was unlikely because she did not have evidence of aortic atherosclerosis or preexisting aortoiliac occlusive disease. Our patient was a 65-year-old woman with a history of MI, and the echocardiography showed a left ventricular mural thrombus. Therefore, we considered that embolic rather than thrombotic occlusion was the proper diagnosis. Making a distinction between embolic and thrombotic AAO is helpful. There are differences in the chosen treatment strategy depending on the type of occlusion. In embolic AAO, thromboembolectomy is the treatment of choice, while in thrombotic AAO, extra-anatomic bypass thrombolysis or thrombo-embolectomy are routinely used [2].

Conclusions

Although rare, left ventricular thrombosis caused by AMI can cause AAO. This is because patients with AMI typically receive long-term antiplatelet therapy, which often runs counter to thrombus formation. In this case report, the patient presented with acute lower extremity pain and weakness, high levels of D-dimer, and a CTA suggestive of an occlusive abdominal aortic thrombus. This made the diagnosis much easier. Although the patient in this case did not have a good prognosis, early diagnosis and timely surgical intervention remain the best ways to prevent death.

References:

1... Grip O, Wanhainen A, Björck M, Acute aortic occlusion: Circulation, 2019; 1392; 292-94

2... Grip O, Wanhainen A, Björck M, Temporal trends and management of acute aortic occlusion: A 21 year experience: Eur J Vasc Endovasc Surg, 2019; 585; 690-96

3... Wong SSN, Roche-Nagle G, Oreopoulos G, Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome: J Vasc Surg, 2013; 571; 218-20

4... Shiraishi M, Kimura C, Yamaguchi A, Adachi H, Secondary aortoenteric fistula: A case report of acute aortic occlusion following cellulitis: Ann Thorac Cardiovasc Surg, 2012; 186; 557-59

5... McClain RL, Pai S-L, Acute aortic occlusion presenting as paraplegia: A catastrophic complication in an elective surgical patient: A A Case Rep, 2013; 14; 64-66

6... Collins D, Moloney MA, O’Donnell D, Acute aortic occlusion in a patient with heparin-induced thrombocytopenia treated by thrombectomy: Ir J Med Sci, 2012; 1813; 397-400

7... Hines GL, Liu HH, Acute aortic occlusion and its sequelae: Metabolic, pathologic etiology, and management: Cardiol Rev, 2021; 292; 57-61

8... Thompson JE, Weston AS, Sigler L, Arterial embolectomy after acute myocardial infarction. A study of 31 patients: Ann Surg, 1970; 1716; 979-86

9... Yarımoglu R, Yarımoglu S, Tastan H, Erkengel HI, Acute infrarenal abdominal aortic occlusion in a patient with COVID-19: Ann Saudi Med, 2021; 416; 392-95

10... Lee R, Hsu R, Acute aortic occlusion associated with COVID-19: A rare complication of a not so rare disease: J Am Coll Emerg Physicians Open, 2022; 33; e12730

11... Minalyan A, Thelmo FL, Chan V, Severe acute respiratory syndrome coronavirus 2-induced acute aortic occlusion: A case report: J Med Case Rep, 2021; 151; 112

12... Burley NB, Dy PS, Kalantri S, Razzaq K, Aortic thrombosis and acute limb ischemia secondary to COVID hypercoagulability: Cureus, 2021; 137; e16171

13... Philip AM, George LJ, John KJ, A review of the presentation and outcome of left ventricular thrombus in coronavirus disease 2019 infection: J Clin Transl Res, 2021; 76; 797-808

14... Sieber S, Stoklasa K, Reutersberg B, Acute abdominal aortic occlusion: A 16-year single-center experience: J Vasc Surg, 2021; 74(6); 1894-903 e3

In Press

Case report  Italy

Morbihan Disease: A Rare Case of Periorbital Bilateral Edema with Histopathological Findings of Chronic Inf...

Am J Case Rep In Press; DOI: 10.12659/AJCR.943421  

Case report  Poland

Lung Lesions: Differential Diagnoses Beyond Cancer

Am J Case Rep In Press; DOI: 10.12659/AJCR.943798  

Case report  USA

Sinus Node Dysfunction Triggered by Tonsillar Abscess: Effects of Vagal Nerve Compression

Am J Case Rep In Press; DOI: 10.12659/AJCR.943944  

Case report  China (mainland)

Genome Sequencing Analysis of a Rare Case of Blood Infection Caused by Flavonifractor plautii

Am J Case Rep In Press; DOI: 10.12659/AJCR.943920  

Most Viewed Current Articles

07 Mar 2024 : Case report  USA 37,955

Neurocysticercosis Presenting as Migraine in the United States

DOI :10.12659/AJCR.943133

Am J Case Rep 2024; 25:e943133

0:00

10 Jan 2022 : Case report  Germany 31,037

A Report on the First 7 Sequential Patients Treated Within the C-Reactive Protein Apheresis in COVID (CACOV...

DOI :10.12659/AJCR.935263

Am J Case Rep 2022; 23:e935263

19 Jul 2022 : Case report  Saudi Arabia 17,673

Atlantoaxial Subluxation Secondary to SARS-CoV-2 Infection: A Rare Orthopedic Complication from COVID-19

DOI :10.12659/AJCR.936128

Am J Case Rep 2022; 23:e936128

23 Feb 2022 : Case report  USA 17,528

Penile Necrosis Associated with Local Intravenous Injection of Cocaine

DOI :10.12659/AJCR.935250

Am J Case Rep 2022; 23:e935250

Your Privacy

We use cookies to ensure the functionality of our website, to personalize content and advertising, to provide social media features, and to analyze our traffic. If you allow us to do so, we also inform our social media, advertising and analysis partners about your use of our website, You can decise for yourself which categories you you want to deny or allow. Please note that based on your settings not all functionalities of the site are available. View our privacy policy.

American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923