a mobile aortic thrombus in a non - atherosclerotic , non - aneurysmal aorta and is not a common finding .
a mobile aortic thrombus is a potential source of visceral , cerebral and peripheral embolism .
the management of a mobile aortic thrombus is not well established because of its rare occurrence .
management of a mobile aortic thrombus includes systemic anticoagulation , aortic thromboendarterectomy or covered stenting .
here we describe a case of acute mobile aortic thrombus with renal infarction , which was successfully treated with hybrid surgery using wire - directed balloon catheter thrombectomy .
a 44-year - old woman was diagnosed with advanced gastric cancer ( t4n3 ) for which total gastrectomy was performed .
she received cisplatin ( 92 mg / day for 4 days ) and 5-fluorouracil ( 1,530 mg / day for 1 day ) .
two days after the 1st chemotherapy , the patient presented with a sudden onset of right flank pain and dizziness .
a large thrombus was identified in the abdominal aorta at the origin of the renal arteries , and it involved the right renal artery causing renal infarction ( fig .
the ct scan prior to the chemotherapy showed a normal aorta at the origin of the renal arteries .
initial laboratory findings were within normal limits ; prothrombin time international normalized ratio 1.01 , activated partial thromboplastin time 33.7 seconds , protein c activity 125% , antithrombin iii 108% , blood urea nitrogen 13.8 mg / dl , creatinine 0.74 mg / dl , except for protein s activity 56% .
only protein s activity was lower than the normal limit ( 71 to 103% ) .
a therapeutic intravenous infusion of unfractionated heparin was commenced . to minimize surgical burden to the patient who was on her 17th day after major surgery
a transbrachial aortic angiogram was performed , which revealed a large filling defect in the aorta just at the origin of the renal arteries and there was no flow to the right renal artery .
a cut - down of the right common femoral artery and a puncture of the left common femoral artery were performed . after gaining percutaneous access , a 10  40 mm balloon ( ev3 inc . ,
plymouth , mn , usa ) was placed to occlude the left iliac artery to prevent contralateral embolization .
and then , a 5  20 mm balloon ( cordis co. , miami lakes , fl , usa ) was used to occlude the left renal artery ( fig .
wire - directed balloon catheter thrombectomy was performed using a 5f over - the - wire fogarty catheter ( lemaitre vascular inc . ,
the aortic thrombus was macerated using a trerotola mechanical thrombectomy device ( arrow international inc . , reading , pa , usa ) .
a wire - directed balloon catheter thrombectomy was then performed using a 27 mm equalizer balloon catheter ( boston scientific , cork , ireland , usa ) .
the completion angiogram demonstrated no residual thrombus with no embolus in the left renal artery or in the bilateral lower extremity arterial systems ( fig .
3 ) . left renal balloon occlusion was maintained for 41 seconds and the left kidney function was preserved after reperfusion .
we used about 150 ml of contrast media ( visipaque injection , 270 mgi / ml ; amersham health , cork , ireland ) and the postoperative creatinine level was 0.98 mg / dl .
chemotherapy was stopped after thrombectomy and the patient received systemic heparinization for 1 week and then received antiplatelets including aspirin , cilostazol , and atorvastatin calcium , indefinitely .
follow - up ct scan 7 days after the procedure showed complete resolution of the thrombus ( fig .
eighteen days after the procedure , chemotherapy was restarted with only 5-fluorouracil , because cisplatin has renal toxicity and can cause another thrombus .
mobile aortic thrombus is a rare pathology and is an important source of arterial emboli .
mobile aortic thrombus mostly occurs in the distal aortic arch in the presence of severe diffuse atherosclerotic disease and has been reported in hypercoagulable patients . in our case , however , the mobile aortic thrombus is thought to have developed due to the chemotherapy as there was no evidence of atherosclerotic disease , aneurysmal dilatation of the aorta . because protein s activity was diminished , there is the possibility of protein s deficiency . but
chemotherapy agents have been documented as possible causes of acute arterial thrombosis licciardello et al .   reported that cisplatin induced increase in the von willebrand factor concentration , which increases the risk of arterial occlusive complications .
unfortunately , the von willebrand factor concentrations in this patient were not investigated before chemotherapy . while there are increasing number of reports on thoracoabdominal aortic thrombus as a cause of embolism , the optimal treatment is remains controversial .
systemic anticoagulation , aortic thromboendarterectomy or placement of stent graft were reported as treatments of a mobile aortic thrombus [ 5 - 8 ] .
complete disappearance or a reduction in the size of the thrombus has been reported with the use of anticoagulation alone .
kim et al .   suggested a strategy beginning with low molecular weight heparin as the first line of treatment , followed by surgical thrombus removal if the thrombus persists or recurrent embolism occurs during anticoagulation therapy . in contrast , other investigators have recommended an aggressive surgical approach using aortic thromboendarterectomy .
the management of mobile aortic thrombus is not well established because of its rarity , and there are few comparative studies .
recently , some cases were reported in the literatures that support the endovascular approach of aortic thrombus .
they attempted to manage mobile thrombus of the thoracic aorta with endovascular approach , specifically with stent graft , and showed successful results .
however , our case could not be treated with a covered stent because the aortic thrombus was in the aorta right at the origin of the renal arteries .
so , we performed thrombectomy using a wire - directed balloon catheter with occlusion balloons . another method to prevent distal embolization is using a filter , which was not available in our institution . in our case ,
therefore , we used a mechanical thrombectomy device for maceration of the aortic thrombus ; trerotola device ( arrow international inc . ) with a 5f rotating nitinol basket fragmentation cage .
we intended the wires of the basket directly contact the thrombus , not injuring the aortic wall , and we carefully performed maceration of the aortic thrombus . yet
, it has risks of peripheral embolization of the clot particles and vessel wall injury . because of the irreversible infarction of the right kidney at more than 29 hours
, we did not perform wire - directed thrombectomy for the right renal thrombus . in our case ,
chemotherapy was discontinued after hybrid treatment and the patient took systemic heparinization for 1week , then oral antiplatelets .
antiplatelets have a proven efficacy in acute treatment and prevention of arterial thrombosis because a thrombus that forms in arteries are rich in platelets , as opposed to a fibrin - rich thrombus that forms in veins . in conclusion
, we report here on the successful treatment of a mobile abdominal aortic thrombus by hybrid treatment performing balloon catheter thrombectomy .
our case shows that this technique is a feasible , minimally invasive treatment for a symptomatic mobile abdominal aortic thrombus .
 acute mobile thrombus of the abdominal aorta after chemotherapy is a very unusual finding , which can be a potential source of arterial embolism . 
 we report here on a case of an acute mobile aortic thrombus with renal infarction . 
 we successfully treated the patient with hybrid operation - open surgical and endovascular approach . 
 our case shows that hybrid treatment using wire - directed balloon catheter thrombectomy is a feasible , minimally - invasive treatment for a mobile aortic thrombus . 