From the Research
Management for a patient with 75% stenosis of the infrarenal abdominal aorta due to atherosclerotic changes with a prominent mural thrombus typically requires both medical therapy and consideration for revascularization. The initial approach should include aggressive medical management with antiplatelet therapy (aspirin 81-325 mg daily), high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily), and blood pressure control targeting <130/80 mmHg using ACE inhibitors or ARBs as first-line agents 1. Risk factor modification is essential, including smoking cessation, diabetes management targeting HbA1c <7%, and lifestyle modifications. For this degree of stenosis with mural thrombus, surgical consultation for potential revascularization is warranted, with options including endovascular aneurysm repair (EVAR) or open surgical repair depending on anatomy and patient factors 2. Regular surveillance with duplex ultrasound every 6-12 months is recommended to monitor disease progression. This comprehensive approach addresses both the immediate risk of thromboembolic complications from the mural thrombus and the long-term progression of atherosclerotic disease, while the consideration for intervention is based on the significant stenosis (>70%) which increases risk for ischemic complications. In cases of aspirin resistance, direct oral anticoagulants (DOACs) could be a possible option for managing aortic mural thrombus 1. Endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with a low recurrence and re-embolization rates 3, 4. The best results and absence of recurrences were achieved in patients undergoing immediate exclusion of the PAMT 2.
Some key points to consider:
- Aggressive medical management with antiplatelet therapy, high-intensity statin therapy, and blood pressure control
- Risk factor modification, including smoking cessation and diabetes management
- Surgical consultation for potential revascularization, with options including EVAR or open surgical repair
- Regular surveillance with duplex ultrasound to monitor disease progression
- Consideration of DOACs in cases of aspirin resistance
- Endovascular coverage of the aortic thrombus as a safe and effective procedure.