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Innominate artery aneurysm with thrombus: Detection by two-dimensional echocardiography
lACC Vol 2. No.2
387
August 1983.387-90
Innominate Artery Aneurysm With Thrombus: Detection by Two-Dimensional Echocardiography SAMUEL BUTMAN, MD, FACC, JULIUS M. GARDIN, MD, FACC, MARGARET KNOLL, CVT Long Beach and Irvine. California
A 51 year old man with an innominate artery aneurysm presented with claudication and ischemia of the right forearm and hand. Two-dimensional echocardiography visualized the saccular aneurysm and a pedunculated mobile thrombus within it that were not seen during
The ability to detect intracardiac thrombi noninvasively is important in patients with a history of systemic embolization and in selected patients with left ventricular wall motion abnormalities or mitral stenosis who may have the potential to develop emboli. Two-dimensional echocardiography has become the technique of choice in detecting thrombi because of its relatively high sensitivity and specificity and because it affords a noninvasive evaluation of all the cardiac chambers and valves (1-9). Furthermore, the entire aortic root may be visualized and aortic dissection or fusiform aneurysms identified (10,11). In this report, we describe a patient with a known innominate artery aneurysm in whom a large pedunculated thrombus was visualized during real-time twodimensional echocardiography.
Case Report A 51 year old white man was admitted to the hospital in June 1982 because of progressive right arm claudication. One month before admission, he underwent evaluation including aortic arch angiography for chronic right arm pain. This study revealed a large saccular aneurysm at the origin of the right innominate artery and complete occlusion of the right brachial artery (Fig. 1). The patient had been discharged from the hospital to await definitive surgery. His
From the Cardiology Section, Department of Medicine, Veterans Administration Medical Center, Long Beach, and the Umversity of California, Irvine, Califorrua. Manuscnpt received November 16. 1982; reVised manuscnpt received March 14, 1983, accepted March 16, 1983. Address for reprints: Samuel Butman, MD, Cardiovascular Section. Veterans Administration Medical Center. 5901 East Seventh Street. Long Beach, California 90822
© 1983 by the Amencan College of Cardiology
aortic arch angiography. Two-dimensional echocardiography, shown to be useful in identifying intracardiac masses and aortic aneurysms, may be important in selecting patients with increased risk of embolization.
past medical history included coronary artery bypass surgery for severe angina 2 years before admission. At that time, cardiac catheterization revealed significant three vessel coronary artery disease with normal left ventricular wall motion. On admission in June 1982. physical examination revealed normal vital signs and a normal cardiac examination. On examination of the right arm, absent right brachial, ulnar and radial pulses with mottling, swelling and diminished sensation of the first, second, fourth and fifth digits were noted. An electrocardiogram was within normal limits. The chest X-ray film showed a right paratracheal mass, unchanged since the examination 1 month previously (Fig. 2). Treatment with intravenous heparin resulted in only minimal improvement in perfusion of the right forearm and hand. On the seventh hospital day, a two-dimensional echocardiogram was performed to rule out an intracardiac source for emboli. Left ventricular wall motion was normal and there was no evidence of mural thrombus. Examination of the aortic root and arch from the suprasternal window showed the innominate artery aneurysm enclosing a large, highly mobile, pedunculated mass (Fig. 3). On the ninth hospital day, the patient suddenly developed left-sided weakness and became comatose later that evening. The partial thromboplastin time was within the therapeutic range and the heparin infusion had not been interrupted since admission. Computed axial tomography disclosed a large cerebellar infarction without evidence of bleeding. The patient never regained consciousness and died 21 days after admission. Postmortem examination revealed brain stem and cerebellar infarction. A saccular aneurysm at the origin of the right innominate artery with a large mural thrombus within
0735-1097/83/$3 00
388
BUTMAN ET AL. INNOMINATE ARTERY ANEURYSM
lACC Vol. 2, No 2 August 1983 387-90
Figure 1. A, Selective angiogram of the right brachial artery shows complete occlusionin its midportion. B, Subtraction images during aortic root angiography in the left anterior oblique view reveal a saccular, lobulated aneurysm at the origin of the innominate artery. The aneurysm docs not involve the left common carotid artery, which has a common origin with the innominate artery.
the aneurysm was noted. The aneury smal wall was ulcerated and extended into the trachea.
Discussion Aneurysms of the innominate artery are relatively uncommon. Arteriosclerosis, trauma and infection are the usual causes of the formation of an aneu rysm in the innominate and subclavian arteries (12, 13). A patient with an innom inate artery aneurysm secondary to arteriosclerosis generally presents with an asymptomatic superior mediastinal mass on chest X-ray film, or because of finding s such as dysphagia, hoarseness, Homer's syndrome , supraclavicular pain, dysfunction of the brachia l plexus with pain or varying degrees of weakne ss , upper compartment edema and transient ischemic attack s or stroke (12 ,14). The definitive diagnosis of this lesion generally is made by angiography , which aids in excluding other vascular lesions and superior mediastinal masses ; computed axial tomography has also been reported to be useful in identifying aneury sms in the ascending and transverse aorta (12,15).
Role of two-dimensional echocardiography. In our patient , two-dimensional echo cardiography was perform ed to rule out the possibility of a cardiac source of the apparent embolization to the right brachial artery. This study revealed normal left ventricular wall motion and no evidence of left ventricular clot. An attempt to visualize the innominate artery aneury sm revealed the aneurysm and , with in it, a pedunculated mobile mass not visualized on arch angiography. At postmortem examination , the mural thrombus within the aneurysm was a nonpedunculated mass , suggesting that the brain stem and cerebellar infarction that led to the patient ' s death may have been due to embolization of the mobile mass seen with two-dimension al echocard iograph y. Visualization of intracardiae thrombi. The identification of intracardiac thrombi with two-dimensional echo cardiography has been reported by many investigators ( 19), leading to the widespread use of this technique in patients suspected of having systemic embolization from a cardiac source. Thrombi have been detected in the left ventricle, left atrium and right atrium by several investigators (5, 8,9) with relatively good sensitivity and specificity reported. Other
JACC Vol. 2. No 2 August 1983387-90
389
BUTMAN ET A,L. INNOMINATE ARTERY ANEURYSM
techniques, such as angiography or indium-III plateletscintigraphy, which is reportedly lesssensitive but morespecific than echocardiography, also have a role in the detection of cardiac thrombi (16,17). However, two-dimensional echocardiography, because it is noninvasive, safe and rapid, is the method of choice in the majority of medical centers today. Visualization of intraaortic and intraarterial thrombi. To our knowledge, detection of thrombi within
Figure 2. Chest X-ray film in the posteroanterior projection reveals a large right paratracheal mass. Surgical clips are present from previous coronary artery bypass surgery.
Figure 3. Suprasternal short-axis echocardiographic frames demonstrate the saccular innominate arteryaneurysm (An). The thrombus (arrow), which was attached by a thin stalk to the wall of the aneurysm, is visualized initially in early systole (8), is best seen in midsystole (D) and then disappears from the image in early diastole (F).
aneurysms in the thoracic aorta has not been reported . Detection of a pedunculated thrombus is clinically relevant because of the high risk of embolization of this form of thrombus, compared with mural thrombi, which are not uncommon in patients with left ventricular dysfunction or recent myocardial infarction (5,18) . The configuration of thrombi recorded by two-dimensional echocardiography may be valuable in determining the risk of subsequent embolization. Shaggy, irregular borders and marked mobility during the cardiac cycle generally suggest friability and high embolic potential , whereas well circumscribed and immobile thrombi generally are less likely to embolize (5). In summary, two-dimensional echocardiography was used to visualize an innominate artery aneurysm in which a pedunculated thrombus was identified. Further study is necessary to assess the sensitivity and specificity of this technique in detecting thoracic aortic aneurysms and associated mural thrombi .
We thank Wilma Mouin for her excellent secretarial assistance preparation of this manuscript.
In
the
390
BUTMAN ET AL INNOMINATE ARTERY ANEURYSM
References I. Mikell FL, Asinger RW, Elsperger KJ, Anderson WR, Hodges M. Regional stasis of blood in the dysfunctional left ventricle' echocardiographic detection and dtfferentiation from early thrombus. Circulation 1982;66:755-63.
2. Asinger RW. Mikell FL. Sharma B. Hodges M. Observations on detecting left ventricular thrombus with two-drmensional cchocardiography. Emphasis on avoidance of false positive diagnoses. Am J Cardiol 1981 ;47:145-56. 3. Asinger RW. Mikell FL, Elsperger J. Hodges M. Incidence of left ventricular thrombus after acute transmural myocardial mfarcuon, Serial evaluation by two-dimensional echocardiography. N Engl J Med 1981 ;305:297- 302. 4. Mikell FL, Asinger RW, Elsperger KJ, Anderson WR, Hodges M. Tissue acoustic properties of fresh left ventricular thrombi and visuahzauon by two-dimensional echocardiography: experimental observatrons , Am J CardioI1982;49:1157-65. 5. DeMaria AN. Bommer W, Neumann A. et at. Left ventricular thrombi Identified by cross-sectional echocardiography, Ann Intern Med 1979;90:14- 8. 6. Schweizer P. Bardos P, Erbel R. et at. Detection of left atrial thrombi by echocardiography. Br Heart J 1981;45:148-56 . 7. Riggs T, Paul MH, Deleon S. llbawi M. Two-dimensional echocardiography in evaluation of right atrial masses: five cases in pediatric patients. Am J Cardiol 1981,48:961- 6. 8. DePace NL. Soulen RL, Kotler MN. MIntz GS. Two-dtmensional echocardiographic detection of mtraatnal masses. Am J Cardiel 1981;48:954- 60.
lA CC Vol 2. No 2 Augu't 1983 387-90
9. Stratton JR, Lighty GW, Pearlman AS, Ritchie JL. Detection of left ventricular thrombus by two-dimensional echocardiography: sensitivuy, spccificuy, and causes of uncertainty. Circulation 1982;66:15666. 10. DeMaria AN. Bommer W. Neumann A. Weinert L, Bogren H. Mason DT. Identificationand localization of aneurysms of the ascendmg aorta by cross-sectional echocardrography. Circulation 1979;59:755-61 . II . Mintz GS. Kotler MN, Segal BL, Parry WR. Two dimensional echocardiographic recognition of the descending thoracic aorta Am J Cardiol 1979;44:232- 8. 12. Schumacher PD, Wright CB. Management of arteriosclerotic aneurysm of the innominate artery. Surgery 1979:85:489-95. 13. Tadavarthy M, Casteneda-Zuniga WR. Klugman J, Shachar JB, Amplatz K. Syphilhtic aneurysms of the innominate artery. Radiology 1981;139:31-4 . 14. Thomas TV. Intrathoracic aneurysms of the innommate and subclavian arteries. J Thorac Cardiovasc Surg 1972:63:461 - 71. 15. Sanders JH. Malave S, Neiman HL, Moran JM, Roberts AJ, Michaelis LL. Thoracic aortic imaging without angiography. Arch Surg 1979;114:1236-329. 16 Ezekowitz MD, Wilson BA, Smith EO, et at. Comparison of mdiumIII platelet scintigraphy and two-dimensional echocardiography in the diagnosis of left ventricularthrombi. N Engl J Med 1982;306:150913. 17. Hamby RI, Wisoff BG, DavisonST. Coronary artery disease and left ventricular mural thrombi: climcal, hemodynamic and angiographic aspects. Chest 1974;56:488-91. 18. Chen CC, Webster GW. Morganroth J. Large mobile pedunculated left ventricular thrombus. identification by two-dimensional echocardiography. Clin Cardlol 1981.4:189-92.
387
August 1983.387-90
Innominate Artery Aneurysm With Thrombus: Detection by Two-Dimensional Echocardiography SAMUEL BUTMAN, MD, FACC, JULIUS M. GARDIN, MD, FACC, MARGARET KNOLL, CVT Long Beach and Irvine. California
A 51 year old man with an innominate artery aneurysm presented with claudication and ischemia of the right forearm and hand. Two-dimensional echocardiography visualized the saccular aneurysm and a pedunculated mobile thrombus within it that were not seen during
The ability to detect intracardiac thrombi noninvasively is important in patients with a history of systemic embolization and in selected patients with left ventricular wall motion abnormalities or mitral stenosis who may have the potential to develop emboli. Two-dimensional echocardiography has become the technique of choice in detecting thrombi because of its relatively high sensitivity and specificity and because it affords a noninvasive evaluation of all the cardiac chambers and valves (1-9). Furthermore, the entire aortic root may be visualized and aortic dissection or fusiform aneurysms identified (10,11). In this report, we describe a patient with a known innominate artery aneurysm in whom a large pedunculated thrombus was visualized during real-time twodimensional echocardiography.
Case Report A 51 year old white man was admitted to the hospital in June 1982 because of progressive right arm claudication. One month before admission, he underwent evaluation including aortic arch angiography for chronic right arm pain. This study revealed a large saccular aneurysm at the origin of the right innominate artery and complete occlusion of the right brachial artery (Fig. 1). The patient had been discharged from the hospital to await definitive surgery. His
From the Cardiology Section, Department of Medicine, Veterans Administration Medical Center, Long Beach, and the Umversity of California, Irvine, Califorrua. Manuscnpt received November 16. 1982; reVised manuscnpt received March 14, 1983, accepted March 16, 1983. Address for reprints: Samuel Butman, MD, Cardiovascular Section. Veterans Administration Medical Center. 5901 East Seventh Street. Long Beach, California 90822
© 1983 by the Amencan College of Cardiology
aortic arch angiography. Two-dimensional echocardiography, shown to be useful in identifying intracardiac masses and aortic aneurysms, may be important in selecting patients with increased risk of embolization.
past medical history included coronary artery bypass surgery for severe angina 2 years before admission. At that time, cardiac catheterization revealed significant three vessel coronary artery disease with normal left ventricular wall motion. On admission in June 1982. physical examination revealed normal vital signs and a normal cardiac examination. On examination of the right arm, absent right brachial, ulnar and radial pulses with mottling, swelling and diminished sensation of the first, second, fourth and fifth digits were noted. An electrocardiogram was within normal limits. The chest X-ray film showed a right paratracheal mass, unchanged since the examination 1 month previously (Fig. 2). Treatment with intravenous heparin resulted in only minimal improvement in perfusion of the right forearm and hand. On the seventh hospital day, a two-dimensional echocardiogram was performed to rule out an intracardiac source for emboli. Left ventricular wall motion was normal and there was no evidence of mural thrombus. Examination of the aortic root and arch from the suprasternal window showed the innominate artery aneurysm enclosing a large, highly mobile, pedunculated mass (Fig. 3). On the ninth hospital day, the patient suddenly developed left-sided weakness and became comatose later that evening. The partial thromboplastin time was within the therapeutic range and the heparin infusion had not been interrupted since admission. Computed axial tomography disclosed a large cerebellar infarction without evidence of bleeding. The patient never regained consciousness and died 21 days after admission. Postmortem examination revealed brain stem and cerebellar infarction. A saccular aneurysm at the origin of the right innominate artery with a large mural thrombus within
0735-1097/83/$3 00
388
BUTMAN ET AL. INNOMINATE ARTERY ANEURYSM
lACC Vol. 2, No 2 August 1983 387-90
Figure 1. A, Selective angiogram of the right brachial artery shows complete occlusionin its midportion. B, Subtraction images during aortic root angiography in the left anterior oblique view reveal a saccular, lobulated aneurysm at the origin of the innominate artery. The aneurysm docs not involve the left common carotid artery, which has a common origin with the innominate artery.
the aneurysm was noted. The aneury smal wall was ulcerated and extended into the trachea.
Discussion Aneurysms of the innominate artery are relatively uncommon. Arteriosclerosis, trauma and infection are the usual causes of the formation of an aneu rysm in the innominate and subclavian arteries (12, 13). A patient with an innom inate artery aneurysm secondary to arteriosclerosis generally presents with an asymptomatic superior mediastinal mass on chest X-ray film, or because of finding s such as dysphagia, hoarseness, Homer's syndrome , supraclavicular pain, dysfunction of the brachia l plexus with pain or varying degrees of weakne ss , upper compartment edema and transient ischemic attack s or stroke (12 ,14). The definitive diagnosis of this lesion generally is made by angiography , which aids in excluding other vascular lesions and superior mediastinal masses ; computed axial tomography has also been reported to be useful in identifying aneury sms in the ascending and transverse aorta (12,15).
Role of two-dimensional echocardiography. In our patient , two-dimensional echo cardiography was perform ed to rule out the possibility of a cardiac source of the apparent embolization to the right brachial artery. This study revealed normal left ventricular wall motion and no evidence of left ventricular clot. An attempt to visualize the innominate artery aneury sm revealed the aneurysm and , with in it, a pedunculated mobile mass not visualized on arch angiography. At postmortem examination , the mural thrombus within the aneurysm was a nonpedunculated mass , suggesting that the brain stem and cerebellar infarction that led to the patient ' s death may have been due to embolization of the mobile mass seen with two-dimension al echocard iograph y. Visualization of intracardiae thrombi. The identification of intracardiac thrombi with two-dimensional echo cardiography has been reported by many investigators ( 19), leading to the widespread use of this technique in patients suspected of having systemic embolization from a cardiac source. Thrombi have been detected in the left ventricle, left atrium and right atrium by several investigators (5, 8,9) with relatively good sensitivity and specificity reported. Other
JACC Vol. 2. No 2 August 1983387-90
389
BUTMAN ET A,L. INNOMINATE ARTERY ANEURYSM
techniques, such as angiography or indium-III plateletscintigraphy, which is reportedly lesssensitive but morespecific than echocardiography, also have a role in the detection of cardiac thrombi (16,17). However, two-dimensional echocardiography, because it is noninvasive, safe and rapid, is the method of choice in the majority of medical centers today. Visualization of intraaortic and intraarterial thrombi. To our knowledge, detection of thrombi within
Figure 2. Chest X-ray film in the posteroanterior projection reveals a large right paratracheal mass. Surgical clips are present from previous coronary artery bypass surgery.
Figure 3. Suprasternal short-axis echocardiographic frames demonstrate the saccular innominate arteryaneurysm (An). The thrombus (arrow), which was attached by a thin stalk to the wall of the aneurysm, is visualized initially in early systole (8), is best seen in midsystole (D) and then disappears from the image in early diastole (F).
aneurysms in the thoracic aorta has not been reported . Detection of a pedunculated thrombus is clinically relevant because of the high risk of embolization of this form of thrombus, compared with mural thrombi, which are not uncommon in patients with left ventricular dysfunction or recent myocardial infarction (5,18) . The configuration of thrombi recorded by two-dimensional echocardiography may be valuable in determining the risk of subsequent embolization. Shaggy, irregular borders and marked mobility during the cardiac cycle generally suggest friability and high embolic potential , whereas well circumscribed and immobile thrombi generally are less likely to embolize (5). In summary, two-dimensional echocardiography was used to visualize an innominate artery aneurysm in which a pedunculated thrombus was identified. Further study is necessary to assess the sensitivity and specificity of this technique in detecting thoracic aortic aneurysms and associated mural thrombi .
We thank Wilma Mouin for her excellent secretarial assistance preparation of this manuscript.
In
the
390
BUTMAN ET AL INNOMINATE ARTERY ANEURYSM
References I. Mikell FL, Asinger RW, Elsperger KJ, Anderson WR, Hodges M. Regional stasis of blood in the dysfunctional left ventricle' echocardiographic detection and dtfferentiation from early thrombus. Circulation 1982;66:755-63.
2. Asinger RW. Mikell FL. Sharma B. Hodges M. Observations on detecting left ventricular thrombus with two-drmensional cchocardiography. Emphasis on avoidance of false positive diagnoses. Am J Cardiol 1981 ;47:145-56. 3. Asinger RW. Mikell FL, Elsperger J. Hodges M. Incidence of left ventricular thrombus after acute transmural myocardial mfarcuon, Serial evaluation by two-dimensional echocardiography. N Engl J Med 1981 ;305:297- 302. 4. Mikell FL, Asinger RW, Elsperger KJ, Anderson WR, Hodges M. Tissue acoustic properties of fresh left ventricular thrombi and visuahzauon by two-dimensional echocardiography: experimental observatrons , Am J CardioI1982;49:1157-65. 5. DeMaria AN. Bommer W, Neumann A. et at. Left ventricular thrombi Identified by cross-sectional echocardiography, Ann Intern Med 1979;90:14- 8. 6. Schweizer P. Bardos P, Erbel R. et at. Detection of left atrial thrombi by echocardiography. Br Heart J 1981;45:148-56 . 7. Riggs T, Paul MH, Deleon S. llbawi M. Two-dimensional echocardiography in evaluation of right atrial masses: five cases in pediatric patients. Am J Cardiol 1981,48:961- 6. 8. DePace NL. Soulen RL, Kotler MN. MIntz GS. Two-dtmensional echocardiographic detection of mtraatnal masses. Am J Cardiel 1981;48:954- 60.
lA CC Vol 2. No 2 Augu't 1983 387-90
9. Stratton JR, Lighty GW, Pearlman AS, Ritchie JL. Detection of left ventricular thrombus by two-dimensional echocardiography: sensitivuy, spccificuy, and causes of uncertainty. Circulation 1982;66:15666. 10. DeMaria AN. Bommer W. Neumann A. Weinert L, Bogren H. Mason DT. Identificationand localization of aneurysms of the ascendmg aorta by cross-sectional echocardrography. Circulation 1979;59:755-61 . II . Mintz GS. Kotler MN, Segal BL, Parry WR. Two dimensional echocardiographic recognition of the descending thoracic aorta Am J Cardiol 1979;44:232- 8. 12. Schumacher PD, Wright CB. Management of arteriosclerotic aneurysm of the innominate artery. Surgery 1979:85:489-95. 13. Tadavarthy M, Casteneda-Zuniga WR. Klugman J, Shachar JB, Amplatz K. Syphilhtic aneurysms of the innominate artery. Radiology 1981;139:31-4 . 14. Thomas TV. Intrathoracic aneurysms of the innommate and subclavian arteries. J Thorac Cardiovasc Surg 1972:63:461 - 71. 15. Sanders JH. Malave S, Neiman HL, Moran JM, Roberts AJ, Michaelis LL. Thoracic aortic imaging without angiography. Arch Surg 1979;114:1236-329. 16 Ezekowitz MD, Wilson BA, Smith EO, et at. Comparison of mdiumIII platelet scintigraphy and two-dimensional echocardiography in the diagnosis of left ventricularthrombi. N Engl J Med 1982;306:150913. 17. Hamby RI, Wisoff BG, DavisonST. Coronary artery disease and left ventricular mural thrombi: climcal, hemodynamic and angiographic aspects. Chest 1974;56:488-91. 18. Chen CC, Webster GW. Morganroth J. Large mobile pedunculated left ventricular thrombus. identification by two-dimensional echocardiography. Clin Cardlol 1981.4:189-92.