Performing intravascular procedures in highly inflammatory patients: think twice.

Background: Intra-aortic thrombi with systemic embolization are rare but potentially life-threatening conditions. Known risk factors include hypercoagulability (e.g. due to inflammation) and atherosclerosis.

Case summary: We present a 46-year-old female patient presenting with highly elevated inflammatory parameters due to an atypical community-acquired pneumonia. Stabbing chest pain at admission, negative anterolateral and inferior T-waves on the electrocardiogram and a rise in high-sensitivity troponin T level indicated a diagnostic coronarography which showed no significant coronary stenosis, prompting the diagnosis of an infectious perimyocarditis. Four days after the angiography, the patient experienced multiple systemic thromboembolic events within a timeframe of 24 hours due to a large intra-aortic thrombus.

Discussion: The co-occurrence of aortic thrombi following a coronary angiography in a highly inflammatory patient raises the suspicion of inflammation-induced arterial thrombosis subsequent to endothelial cell injury. An overwhelming inflammatory response will increase the levels of coagulation factor VIII - produced by the endothelium and acting as an acute phase protein - and thus the tendency to form blood clots, especially after local damage to the endothelial cells by guidewire or catheter manipulation. Within this case report, we underscore the importance of adopting a cautious strategy when contemplating invasive arterial procedures, or even postpone when not urgently needed, in patients with strongly elevated levels of inflammation. Here, factor VIII levels can act as a guidance even before C-reactive protein levels rise. These interventions carry the risk of causing endothelial cell injury, consequently amplifying the probability of arterial thrombus formation, with a challenging management and treatment.