Diagnosis and Management of Carotid Free-Floating Thrombus: A Systematic Literature Review

A review was performed of MEDLINE, Embase, and manually for references from 1960 to June 2017.

The authors identified 525 carotid free-floating thrombus cases. About a third of cases were identified using digital subtraction angiography, a third with duplex ultrasound (DU), and a third with computed tomography angiography. Carotid free-floating thrombi were present in 1.5% of stroke patients. The 30-day risk of transient ischemic attack, silent brain ischemia, stroke, or death was 17%. In multivariate analyses, there were no differences in outcome for anticoagulation or timing of revascularization (before or after 3 days).

Diagnosis of carotid free-floating thrombus is more common because of increased use of DU. The lesion poses a high short-term risk of stroke and death, but there is no definite answer for treatment in terms of anticoagulation or timing of intervention.

Although this is a rare entity, most vascular surgeons will come across a free-floating carotid thrombus sometime during their careers. One is tempted to immediately anticoagulate a patient with a carotid free-floating thrombus and to operate or place a stent within a day or two for fear of a large embolus traveling to the brain if the interventionalist waits too long. Although the authors attempted to answer whether the best strategy is anticoagulation and early surgery, this is a retrospective review that limited any conclusions.
儘管這是一種罕見的疾病，但大多數血管外科醫生在其職業生涯中的某個時候都會遇到自由漂浮的頸動脈血栓。人們傾向於立即對患有頸動脈自由漂浮血栓的患者進行抗凝血治療，並在一兩天內進行手術或放置支架，因為擔心如果介入醫生等待太久，大的栓子會進入大腦。儘管作者試圖回答最佳策略是否是抗凝血和早期手術，但這是一項回顧性綜述，限制了任何結論。

A previous review of the literature reported that at least 92% of patients with carotid free-floating thrombus were symptomatic.¹

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Bhatti AF, Leon LR, Labropoulos N, Rubinas TL, Rodriguez H, Kalman PG, et al. Free-floating thrombus of the carotid artery: literature review and case reports. J Vasc Surg 2007;45:199-205.

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Almost half of patients tested serologically were hypercoagulable. About two-thirds were managed with surgery (≤7 days in 82% [79/96]), and 9% (36/67) of these patients worsened postoperatively. One-third were managed using anticoagulation or antiplatelet agents, and only 3% (1/35) worsened after 1 month. Complete dissolution of the thrombus without further neurologic events occurred in 86% of patients treated medically. This article suggests an intriguing approach using a combined strategy. Although I cannot say I would recommend this protocol in every patient with a carotid free-floating thrombus, I would lean toward administration of anticoagulation and antiplatelet agents for several weeks, followed by carotid endarterectomy if follow-up DU confirms continued presence of the thrombus or >70% to 80% internal carotid stenosis.
先前的文獻回顧報告稱，至少 92% 的頸動脈自由漂浮血栓患者有症狀。 ¹

1.

Bhatti AF, Leon LR, Labropoulos N, Rubinas TL, Rodriguez H, Kalman PG, et al. Free-floating thrombus of the carotid artery: literature review and case reports. J Vasc Surg 2007;45:199-205.

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幾乎一半的血清學檢測患者處於高凝血狀態。約三分之二的患者以手術進行治療（82% [79/96] 中≤7 天），其中 9% (36/67) 的患者術後病情惡化。三分之一的患者使用抗凝血或抗血小板藥物進行治療，只有 3% (1/35) 的患者在 1 個月後病情惡化。 86% 接受藥物治療的患者血栓完全溶解，沒有進一步的神經系統事件。本文提出了一種使用組合策略的有趣方法。雖然我不能說我會向每一位患有頸動脈自由浮動血栓的患者推薦該方案，但我傾向於使用抗凝血劑和抗血小板藥物數週，然後如果隨訪DU 確認血栓持續存在，則進行頸動脈內膜切除術或>70% 至 80% 頸內動脈狹窄。