The pathophysiology of a fluttering cord-like thrombus in the aortic arch is unclear. Thrombophilic states are not always observed in patients with thrombus in the aortic arch. 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 coagulation test did not reveal any coagulopathy. However, mural thrombus and stenosis of the abdominal aorta and obstruction of the right common iliac artery and the left deep femoral artery suggest some kind of thrombophilic state.

Evidence related to management of thrombus in the aorta is very limited. A few teams have reported successful management with anticoagulant therapy [2, 3]. Pharmacological treatment (heparinization), endovascular stenting [4], and surgery have been proposed. Although no comparative data are available, pharmacological treatment is indicated when the risk of thromboembolism is considered to be low. Endovascular stent graft exclusion sometimes carries the risk of procedure-related embolism, especially when the thrombus extends to branches. 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 thrombi have been removed under hypothermic circulatory arrest either by distal ascending aortic cannulation [5] or femoral artery cannulation [6]. In the present case, we considered using axillary artery perfusion in order to prevent embolism caused by retrograde perfusion because the patient had mural thrombi in the abdominal aorta and the iliac artery. However, the axillary arteries were small and inappropriate for perfusion, so we used femoral artery perfusion. Fortunately, procedure-related embolism did not occur.

Kalangos et al. reported the successful removal of a thrombus in the proximal ascending aorta without hypothermic circulatory arrest [7]. In this case, because the thrombus extended to the aortic arch, we performed thrombectomy under hypothermic circulatory arrest and selective cerebral perfusion. To prevent distal embolization of the thrombus, we used direct cannulation of the left common carotid artery with clamping at the proximal side. With SACP for brain protection, we were able to remove the thrombus safely and reliably. This technique is considered useful when a thrombus in the aortic arch extends to the neck arteries. In order to use this technique, it is also important to check the location of the thrombus with preoperative CT and carotid ultrasound.

A fluttering cord-like thrombus in the aortic arch may develop in patients who do not have obvious coagulopathy. When a thrombus in the aortic arch extends to the neck arteries, direct cannulation of the neck arteries with selective cerebral perfusion via cervical incision is a useful technique.

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