a 56-year - old man was hospitalized because of pain and numbness in his left hand since he slipped a week earlier .
, we found that the motor and sensory functions of his left hand were normal .
his laboratory data , including anti nuclear antibody , anti - neutrophil cytoplasmic antibody , and rheumatoid arthritis factor , were within normal limits .
however , the laboratory analysis showed decreased protein c and s concentrations ( protein c antigen , 57% ; protein s antigen , 19% ) . the diagnostic work - up to determine the degree of lesion included a computed tomography ( ct ) angiography , which showed an intraluminal lesion of the left upper extremities vessel . in the ct scan ,
coincidently , we stumbled across a mass lesion on the aortic arch . for the evaluation of the incidental mass lesion
, we performed a chest ct scan and transthoracic echocardiography . the ascending aorta and the aortic arch had intact intima and a normal size ( fig .
2 ) . in transthoracic echocardiography , we found a floating mass in the lesser curvature of the aortic arch ( fig .
3 ) . we decided to surgically remove this floating mass because of the risk of peripheral embolization , including thrombectomy for the brachial and radial artery occlusion of the left arm .
a median sternotomy was performed , a venous cannula was inserted in the ra auricle , extracorporeal circulation was begun , and the central temperature was decreased to 25. the patient was then in total circulatory arrest . an incision was made in the aortic arch , and the 3.0-cm intraaortic mass was completely removed ( fig .
the mass had no definite stalk , and its attachment site in the aorta was relatively normal .
we also removed the thrombus of the left upper extremities through the brachial artery . in the postoperative peripheral angiography ,
one week later , the patient recovered without complications and was discharged on the regimen of warfarin .
aortic thrombi , however , are another important cause of arterial thromboembolism . factors related to an arterial thrombus are arteriosclerosis , arterial dissection , trauma , malignant tumor , and hemostatic disorder . in this case , the patient had protein c and s deficiency , which induced a hypercoagulable disorder .
the presence of pedunculated thrombi in the aortic arch as in this case is rare .
the incidence of embolic events from mobile aortic thrombi is 73% . in this case , the patient had a thrombus in his left arm .
they occur more commonly in patients of advanced age and those with several cardiovascular risk factors . in our case
the most frequent location of thoracic aorta thrombi is the region of the aortic isthmus and the portion distal to the aortic arch , at the side opposite to the origin of the subclavian artery .
ct and echocardiography can be used for the diagnosis of aortic thrombi . in particular , transthoracic and transesophageal echocardiography
have high diagnostic accuracy and allow the assessment of the size , morphology , and anchoring site of the thrombus , as well as the characteristics of the aortic wall .
further , to determine the cause of the thrombus , we should consider a survey for hypercoagulable disorder .
a definite diagnosis requires histological and immunohistochemical studies . in a differential diagnosis with other mass lesions , such as tumors ,
the treatment of aortic thrombi is considered necessary because of the risk of a massive systemic embolization .
thrombolysis can be a possible treatment , but there is a risk of thrombolytic agents selectively lysing the stalk of the lesion , releasing the bulk of the lesion into the systemic blood stream .
we believe that in selective patients with acceptable surgery for cardiopulmonary bypass and definite systemic embolic events due to highly mobile aortic thrombi , surgical treatment has been successful .
this case is reported in order to inform the readers of a rare case where floating thrombi in the aortic arch of patients with embolization were successfully treated surgically .
 floating thrombi in the aortic arch are very rare and an unusual source of systemic embolism . herein , a case of a 3-cm thrombus in the aortic arch is reported . 
 it was a floating , highly mobile thrombus attached to the lesser curvature of the aortic arch . 
 the patients had a hypercoagulable disorder induced by protein c and s deficiency . 
 the thrombus was operatively removed with a favorable outcome . 
CASE REPORT
DISCUSSION