Retrograde Aortic Thrombosis with TEVAR for Secondary Stroke Prevention: Case Report

Abstract Proximal aorta thrombi and atheromas have been identified as the source of cardioembolic ischemic stroke. Thrombi and atheromas distal to the carotid and subclavian origins have been overlooked as possible sources; however, descending thoracic aorta thrombi can embolize to the cerebral vasculature during diastolic retrograde aortic flow during diastole. Retrograde aortic flow is described and is capable of reaching the common carotid arteries. This phenomenon has recently been recognized for its stroke potential. Additionally, a complex thrombus in the descending aorta increases the retrograde diastolic flow with potential for these thrombi to cause ischemic stroke. Patients with stroke are more likely to have descending aortic thrombi than patients without stroke. Appropriate secondary stroke prevention for cardioembolic strokes from descending aortic atheroma is unclear. This case report describes a descending aortic thrombus as the likely etiology of a left middle cerebral artery and limb ischemia followed by successful secondary stroke prevention with thoracic endovascular aortic repair (TEVAR). Only one previous case report describes cardioembolic stroke with thrombus originating from a descending aortic atheroma. Endovascular aortic interventions have not been previously described for prevention of strokes in the setting of aortic atheroma.