Thrombus of the Aorta and SARS-CoV-2 Infection: Cause or Trigger?

Objective: Coronavirus disease 19 is a well-established cause of rare arterial thrombosis. Nevertheless, the exact mechanism of arterial thrombosis remains to be elucidated. We herein report the case of a large floating thrombus of the aortic arch, its surgical management and histological analysis.Case: A 65-year-old patient presented to the emergency department with a suspected stroke. He was non-smoker, but presented cardiovascular risk factors, namely hypertension, type 2 diabetes and hyperlipidaemia. A computed tomography of the aorta revealed a large floating thrombus of the aortic arch, at the base of the brachiocephalic trunk, suspected to be the etiology of stroke. Therapeutic anticoagulation was immediately started. The decision was made to perform an open aortic replacement surgery because of the symptomatic thromboembolic event with recent cerebral infarction and the potential harmfulness of the thrombus due to its size. A mobile thrombus was observed at the base of the brachiocephalic trunk by echocardiography. It was attached to a small area of the upper aortic wall and had an irregular surface. Histology revealed a platelet-rich thrombus lying on an aortic atherosclerotic plaque without pronounced inflammation. No plaque ulceration was present but endothelial cell desquamation was observed consistent with plaque erosion.Conclusion: In our case, there was a thrombus lying on an atherosclerotic plaque with intact thick fibrous cap, but associated with a plaque erosion mechanism. The thrombus formation appeared more likely to relate to a very localized endothelial injury.

Download Full-text

A 52-year-old man with asymptomatic giant thoracic-abdominal aortic aneurysm

10.22541/au.161694010.07364081/v1 ◽

2021 ◽

Author(s):

Jianying Deng ◽

Wei Liu

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Aortic Arch ◽

Clinical Symptoms ◽

Ascending Aorta ◽

Local Hospital ◽

Replacement Surgery ◽

Aortic Replacement ◽

Abdominal Aortic ◽

Risk Of Rupture

A 52-year-old man was admitted to our hospital for “CT-diagnosed thoracic-abdominal aortic aneurysm”. One week ago, the patient had repeated dry coughs and went to the local hospital for treatment. A chest radiograph revealed a huge mass in the left thoracic cavity. A further chest CT examination revealed a thoracic-abdominal aortic aneurysm and was transferred to our hospital for surgical treatment.The patient is almost healthy, with no fever, no severe chest and abdomen pain, no dyspnea, no dysphagia or other clinical symptoms. Ten years ago, the patient underwent “ascending aorta and total aortic arch replacement surgery” in another cardiovascular hospital due to aortic dissection involving the ascending aorta and aortic arch (Debakey I).The patient’s thoracic-abdominal aortic aneurysm is huge and has a high risk of rupture. Recently, the patient has undergone thoracic-abdominal aortic replacement surgery and is recovering well.

Download Full-text

Optical Coherence Tomography of Plaque Erosion and Thrombus in Severe Vertebral Artery Stenosis

Diagnostics ◽

10.3390/diagnostics11040638 ◽

2021 ◽

Vol 11 (4) ◽

pp. 638

Author(s):

Lin Yan ◽

Adam A. Dmytriw ◽

Bin Yang ◽

Liqun Jiao

Keyword(s):

Optical Coherence Tomography ◽

Vertebral Artery ◽

Thrombus Formation ◽

Filling Defect ◽

Drug Eluting Stent ◽

Vertebrobasilar Insufficiency ◽

Optical Coherence ◽

Fibrous Cap ◽

Plaque Erosion ◽

Before And After

A 69-year-old male presented with medically refractory vertebrobasilar insufficiency and paroxysmal subjective dizziness for six months. Severe stenosis of a dominant left V2 vertebral artery segment was identified on digital subtraction angiography (DSA) with an irregular intraluminal filling defect immediately above the stenosis. Optical coherence tomography (OCT) demonstrated a normal lumen at the distal end, with red thrombus detected distal to the stenosis. Atherosclerotic plaque containing fibro-lipid was also identified and treated with a drug-eluting stent. Distal red thrombi were not covered by stenting, indicating embolization risk in the future. Clear posterior fossa symptoms occurred after intervention, and treatment with a standard dual antiplatelet regimen and statin therapy was prescribed for one year. Six months after treatment, the symptoms improved, and six-minute walking distances were successful with no gait impairment. To our knowledge, this is the first V2 segment stenosis assessed by OCT imaging before and after stenting, indicating an intact fibrous cap with thrombus formation, as well as plaque erosion. Understanding the role and careful use of OCT may improve the identification of red thrombus and plaque erosion when clinically indicated.

Download Full-text

Total aortic arch replacement surgery with a Core temperature of 34 °C

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-019-1001-0 ◽

2019 ◽

Vol 14 (1) ◽

Cited By ~ 2

Author(s):

Quan Li ◽

Hong Qu ◽

Tianqi Liu ◽

Jianmin Yu ◽

Meng Lv

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Core Temperature ◽

Circulatory Arrest ◽

Surgical Techniques ◽

Neurological Complications ◽

Aortic Arch Replacement ◽

Replacement Surgery ◽

Total Aortic Arch Replacement ◽

Aortic Replacement

Abstract Background Traditional aortic arch replacement surgery must be performed under moderate or deep hypothermia (22–28 °C) and circulatory arrest. Hypothermia and hypoperfusion can cause damage to the nervous system; therefore, postoperative brain and spinal cord complications are common. Improvements in surgical techniques are necessary to solve this problem. Herein, we report a method of total aortic arch replacement that can be performed at a core temperature of 34 °C, similar to other simple cardiac operations. Case presentation Four patients underwent surgery with this technique (3 males and 1 female, aged 48 to 67 years). Computed tomography angiography performed at admission showed a total aortic dissection, resulting in a diagnosis of Stanford type A aortic dissection. The patients underwent emergency aortic sinus remodelling, ascending aortic replacement, modified aortic arch replacement, and elephant trunk stenting. No patients had neurological complications. During a follow-up of more than 1-month, no patients had aortic valve regurgitation or anastomotic leak. Conclusions This technique can increase the operating temperature by approximately 6 to 12 °C and reduce the circulatory arrest time by approximately 18 to 28 min. All of the patients recovered well without any neurological complications, demonstrating the feasibility and safety of this technique. We believe that this technique can serve as a good alternative strategy for managing aortic dissection and aneurysm, especially for young surgeons who are acquiring experience in arch replacement surgery.

Download Full-text

The Modification of Experimental Occlusive Arterial Thrombosis in the Rat by Malayan Pit Viper Venom

Thrombosis and Haemostasis ◽

10.1055/s-0038-1651202 ◽

1968 ◽

Vol 19 (01/02) ◽

pp. 242-247 ◽

Cited By ~ 2

Author(s):

K. E Chan

Keyword(s):

Arterial Thrombosis ◽

Thrombus Formation ◽

Arterial Occlusion ◽

Control Group ◽

Antithrombotic Effect ◽

Daily Dose

SummaryThe effect of Malayan pit viper (Ancistrodon rhodostoma) venom on the fate of experimental arterial thrombosis was studied in rats. A suitable daily dose of venom (500 μg) was used to induce hypofibrinogenaemia in the treated rats for the greater part of each of three consecutive post-operative days.The treated animals showed a statistically significant overall reduction in the incidence of both red thrombus formation and thrombotic arterial occlusion when compared to a control group. This antithrombotic effect of the venom could be observed in the 7-day period following the cessation of the treatment.

Download Full-text

Faculty Opinions recommendation of Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.717969618.793470234 ◽

2013 ◽

Author(s):

Philippe Van der Linden ◽

Yannick Ciccarella

Keyword(s):

Controlled Trial ◽

Fibrinogen Concentrate ◽

First Line ◽

Replacement Surgery ◽

First Line Therapy ◽

Line Therapy ◽

Aortic Replacement

Download Full-text

Passing a Mechanical Aortic Valve With a Short Tip Dilator to Facilitate Aortic Arch Endovascular Branched Repair

Journal of Endovascular Therapy ◽

10.1177/15266028211002506 ◽

2021 ◽

pp. 152660282110025

Author(s):

Nikolaos Konstantinou ◽

Sven Peterss ◽

Jan Stana ◽

Barbara Rantner ◽

Ramin Banafsche ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Arch ◽

Stent Graft ◽

Mechanical Valve ◽

Valve Prosthesis ◽

Proper Position ◽

Mechanical Aortic Valve ◽

Aortic Replacement ◽

Custom Made ◽

Aortic Valve Prosthesis

Purpose To present a novel technique to successfully cross a mechanical aortic valve prosthesis. Technique A 55-year-old female patient with genetically verified Marfan syndrome presented with a 5-cm anastomotic aneurysm of the proximal aortic arch after previous ascending aortic replacement due to a type A aortic dissection in 2007. The patient also underwent mechanical aortic valve replacement in 1991. A 3-stage hybrid repair was planned. The first 2 steps included debranching of the supra-aortic vessels. In the third procedure, a custom-made double branched endovascular stent-graft with a short 35-mm introducer tip was implanted. The mechanical valve was passed with the tip of the dilator on the lateral site of the leaflet, without destructing the valve and with only mild symptoms of aortic insufficiency, as one leaflet continued to work. This allowed the implantation of the stent-graft directly distally of the coronary arteries. Postoperative computed tomography angiography showed no endoleaks and patent coronary and supra-aortic vessels. Conclusion Passing a mechanical aortic valve prosthesis at the proper position is feasible and allows adequate endovascular treatment in complex arch anatomy. However, caution should be taken during positioning of the endovascular graft as the tip may potentially damage the valve prosthesis.

Download Full-text

Macrophage infiltrates in coronary plaque erosion portend a worse cardiovascular outcome in patients with acute coronary syndrome

European Heart Journal ◽

10.1093/ehjci/ehaa946.1250 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R.A Montone ◽

V Vetrugno ◽

M Camilli ◽

M Russo ◽

M.G Del Buono ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Vulnerable Plaque ◽

Cardiac Death ◽

Cox Regression ◽

Plaque Rupture ◽

Culprit Lesion ◽

Coronary Syndrome ◽

Fibrous Cap ◽

Plaque Erosion

Abstract Background Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS). Inflammatory activation is considered a key mechanism of plaque instability in patients with plaque rupture through the release of metalloproteinases and the inhibition of collagen synthesis that in turns lead to fibrous cap degradation. However, the clinical relevance of macrophage infiltration has never been investigated in patients with PE. Purpose In our study, we aimed at assessing the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (MØI) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value. Methods ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of MØI at culprit site and in non-culprit segments along the culprit vessel was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03–2.58) years]. Results We included 153 patients [median age (IQR) 64 (53–75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with MØI and 102 (66.7%) PE without MØI. Patients having PE with MØI compared with PE patients without MØI had more vulnerable plaque features both at culprit site and at non-culprit segments. In particular, culprit lesion analysis demonstrated that patients with PE with MØI had a significantly thinner fibrous cap [median (IQR) 100 (60–120) μm vs. 160 (95–190) μm, p<0.001], higher prevalence of thrombus [41 (80.4%) vs. 64 (62.7%), p=0.028], lipid plaque [39 (76.5%) vs. 50 (49.0%), p<0.001], TCFA [20 (39.2%) vs. 14 (13.7%), p=0.001], and a higher maximum lipid arc [median [IQR] 250.0° (177.5°-290.0°) vs. 190.0° (150.0°-260.0°), p=0.018) at the culprit lesion compared with PE without MØI. MACEs were significantly more frequent in PE with MØI patients compared with PE without MØI [11 (21.6%) vs. 6 (5.9%), p=0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression model, PE with MØI [HR=2.95, 95% CI (1.09–8.02), p=0.034] was an independent predictor of MACEs. Conclusion Our study demonstrates that among ACS patients with PE the presence of MØI at culprit lesion is associated with a more aggressive phenotype of coronary atherosclerosis with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up. These findings are of the utmost importance in the era of precision medicine because clearly show that macrophage infiltrates may identify patients with a higher cardiovascular risk requiring more aggressive secondary prevention therapies and a closer clinical follow-up. Prognosis Funding Acknowledgement Type of funding source: None

Download Full-text

Establishing Background Pathologic Changes of Valve Replacement Surgery in Sheep

Cardiovascular Engineering and Technology ◽

10.1007/s13239-021-00563-6 ◽

2021 ◽

Author(s):

Jill T. Schappa Faustich ◽

John P. Carney ◽

Matthew T. Lahti ◽

Benjamin L. Zhang ◽

Richard W. Bianco

Keyword(s):

Invasive Surgery ◽

Heart Valves ◽

Serum Biochemistry ◽

Preclinical Model ◽

Sheep Model ◽

Safety Issues ◽

Replacement Surgery ◽

Aortic Replacement ◽

Complete Blood Counts ◽

Future Evaluation

Abstract Purpose Sheep are the standard preclinical model for assessing safety of novel replacement heart valves, yet the anatomic and pathologic effects of invasive surgery, including those involving cardiopulmonary bypass (CPB), are unknown. Thus, we aimed to determine the gross, hematologic and biochemical effects of sham mitral and aortic replacement valve procedures in sheep to establish a useful control for evaluation of novel replacement valves. Methods Six control sheep were examined without any surgical intervention. Six sham mitral valve replacements (MVR) and six sham aortic valve replacements (AVR) were performed on 12 sheep. Complete blood counts and serum biochemistry were performed throughout the study. Sheep were sacrificed with a necropsy performed at 90 days. Results Renal infarcts (RIs) were the most frequently observed lesion, averaging 4.7 in control sheep, 2.5 with MVR and 5.8 with AVR. The number of infarcts strongly correlated with total estimated area of infarcted kidney (r = .84, p < .01). Additional cardiac interventions were significantly correlated with increased numbers of RIs (r = .85, p < .01). There was no correlation between number of RIs and time on CPB, or between AVR and MVR procedures. Conclusion The sheep model for AVR and MVR requires invasive surgery and CPB, which are associated with background anatomic and pathologic changes, especially in cases with additional surgical cardiac interventions. These findings serve as a critical control for future evaluation and development of novel replacement valves in order to distinguish device-related safety issues from expected outcomes of the surgical procedure and normal background changes in sheep.

Download Full-text

Different Approaches in Therapy Aiming to Stabilize An Unstable Atherosclerotic Plaque

International Journal of Molecular Sciences ◽

10.3390/ijms22094354 ◽

2021 ◽

Vol 22 (9) ◽

pp. 4354

Author(s):

Michal Kowara ◽

Agnieszka Cudnoch-Jedrzejewska

Keyword(s):

Atherosclerotic Plaque ◽

Clinical Problem ◽

Myocardial Infarctions ◽

Matrix Remodeling ◽

Plaque Erosion ◽

Plaque Stabilization ◽

Regulation Of Metabolism ◽

Alternative Approaches ◽

Unstable Atherosclerotic Plaque ◽

Plaque Destabilization

Atherosclerotic plaque vulnerability is a vital clinical problem as vulnerable plaques tend to rupture, which results in atherosclerosis complications—myocardial infarctions and subsequent cardiovascular deaths. Therefore, methods aiming to stabilize such plaques are in great demand. In this brief review, the idea of atherosclerotic plaque stabilization and five main approaches—towards the regulation of metabolism, macrophages and cellular death, inflammation, reactive oxygen species, and extracellular matrix remodeling have been presented. Moreover, apart from classical approaches (targeted at the general mechanisms of plaque destabilization), there are also alternative approaches targeted either at certain plaques which have just become vulnerable or targeted at the minimization of the consequences of atherosclerotic plaque erosion or rupture. These alternative approaches have also been briefly mentioned in this review.

Download Full-text