From the Guidelines
A mural thrombus in the aorta detected on a CAT scan is a serious condition that requires prompt medical attention, and treatment typically involves anticoagulation therapy and addressing underlying risk factors. The management of this condition should be guided by the most recent and highest quality evidence, which emphasizes the importance of prompt evaluation and treatment to prevent complications such as embolization, stroke, and limb ischemia 1. The European Society of Cardiology (ESC) guidelines recommend the use of computed tomography (CT) as the preferred initial imaging modality for suspected aortic disease, including mural thrombus, due to its high diagnostic accuracy and ability to detect other disease processes that can mimic aortic disease 1. Key aspects of management include:
- Anticoagulation therapy with medications such as heparin, warfarin, or direct oral anticoagulants (DOACs) like apixaban or rivaroxaban
- Addressing underlying risk factors such as hypertension, diabetes, or smoking
- Regular follow-up imaging to monitor the thrombus
- Lifestyle modifications including smoking cessation, regular exercise, and a heart-healthy diet It is essential to consult with a vascular specialist or cardiologist for proper evaluation and management, as the specific treatment approach will depend on individual circumstances, including the location and size of the thrombus, as well as the presence of any underlying aortic disease or other comorbidities 1.
From the Research
Mural Thrombus on CAT Scan Aorta
- Aortic mural thrombus is a rare clinical finding in the absence of aneurysm or atherosclerosis, but an important source of noncardiogenic emboli with a difficult diagnosis and a high rate of complications, including high mortality 2.
- The management of mural thrombus in non-atherosclerotic aorta represents a challenge because no guidelines are available, and should be individualized 2.
- Therapeutic approaches for aortic mural thrombus include:
- Primary disease anticoagulation treatment
- Surgical thrombectomy to solve embolic complications
- Endovascular/classical surgery to exclude the thrombus from the aorta 2
- Historically, therapeutic anticoagulation was proposed as first-line therapy, but it is associated with a 25-50% embolic recurrence rate, thrombus persistence in 35%, and secondary aortic surgery in up to 31% of the cases 2.
- Recent data suggest that endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with a low recurrence and re-embolization rates 2.
- A case report of a large mural thrombus in the non-aneurysmal and non-atherosclerotic ascending aorta suggested that surgical removal and segment of ascending aorta replacement were executed, and the patient had an uneventful recovery 3.
- Another case report of a large mural thrombus in the distal arch of the aorta without atherosclerotic disease showed that therapy with systemic anticoagulation resulted in complete resolution without necessitating any surgical or endovascular interventions 4.
- A systematic review of aortic mural thrombus in the normal or minimally atherosclerotic aorta found that anticoagulation as primary therapy is associated with a higher likelihood of recurrence, a trend toward a higher incidence of complications, and a higher incidence of limb loss, and that aortic surgery should be considered as primary treatment, particularly for those patients at high risk for recurrence 5.
- A study on primary aortic mural thrombus presentation and treatment found that surgical embolectomy, when required, with subsequent anticoagulation, results in limb salvage and allows for eventual resolution of the primary aortic thrombus, and that long-term anticoagulation is required unless the etiologic process resolves 6.