What is the next best step in managing a patient with an aortic‑arch mural thrombus who requires urgent hip fracture repair?

Management of Aortic Arch Mural Thrombus with Urgent Hip Fracture Surgery

Immediate Anticoagulation and Proceed to Surgery

Initiate systemic anticoagulation immediately with unfractionated heparin (bolus 5000 IU or 70-100 IU/kg, followed by continuous infusion adjusted by aPTT) and proceed with urgent hip fracture repair without delay. 1

The hip fracture requires urgent surgical intervention within 48 hours to minimize morbidity and mortality, and the presence of aortic mural thrombus should not delay this life-saving orthopedic procedure. 1

Anticoagulation Protocol

• Start unfractionated heparin immediately to prevent thrombus propagation and further embolization, using either IV bolus (5000 IU or 70-100 IU/kg) followed by continuous infusion, or subcutaneous low molecular weight heparin (enoxaparin 1 mg/kg twice daily). 1

• Monitor activated partial thromboplastin time (aPTT) or activated clotting time to guide heparin dosing throughout the perioperative period. 1

• The goal is to prevent embolic complications from the aortic thrombus while managing the urgent orthopedic condition. 2, 3

Anesthetic Considerations

Proceed with general anesthesia rather than neuraxial blockade given the anticoagulation requirements and embolic risk. 1

• Invasive arterial blood pressure monitoring is essential given the aortic pathology and need for tight hemodynamic control. 1

• Consider central venous pressure monitoring for volume status optimization, particularly important in elderly hip fracture patients who are often hypovolemic. 1

• Maintain normothermia with active warming strategies throughout the procedure. 1

• Optimize fluid management with cardiac output-guided therapy to reduce hospital stay and improve outcomes. 1, 4

Critical Perioperative Management

Avoid hypotension and maintain adequate perfusion pressure to prevent propagation of thrombus or embolic events during the surgical stress period. 1

• Administer 100% oxygen during critical phases of surgery, particularly during cementation if performing arthroplasty. 1

• Monitor for signs of acute embolization including new neurological deficits, acute limb ischemia, or visceral ischemia. 1, 3

• Continue anticoagulation throughout the perioperative period unless active bleeding occurs. 1

Postoperative Surveillance

Maintain therapeutic anticoagulation postoperatively and arrange urgent vascular surgery consultation for definitive management of the aortic thrombus after orthopedic recovery. 2, 3

• Perform comprehensive imaging (CT angiography or transesophageal echocardiography) within 24-48 hours post-hip surgery to reassess thrombus characteristics and plan definitive treatment. 2, 5

• Monitor closely for embolic complications including stroke, limb ischemia, or visceral ischemia in the first 72 hours postoperatively. 3

• Continue supplemental oxygen for at least 24 hours postoperatively as elderly patients are at high risk for hypoxia. 1

Definitive Aortic Thrombus Management

Plan for surgical thrombectomy or endovascular exclusion of the aortic thrombus once the patient has recovered from hip surgery (typically 2-4 weeks). 2, 3

• Anticoagulation alone has a 25-50% embolic recurrence rate and 35% thrombus persistence rate, making it inadequate as sole long-term therapy. 2

• Surgical management (open thrombectomy or endovascular stent-graft coverage) shows superior outcomes with lower recurrence rates (5.7% vs 26.4%) and lower re-embolization rates (9.1% vs 25.7%) compared to anticoagulation alone. 3

• Thrombus location in the aortic arch is a predictor of recurrence (OR 18.3), further supporting definitive surgical intervention after orthopedic recovery. 3

Common Pitfalls to Avoid

• Do not delay hip surgery for extensive aortic imaging or vascular surgery consultation—the hip fracture mortality risk increases significantly with surgical delay beyond 48 hours. 1

• Do not withhold anticoagulation due to bleeding concerns from hip surgery—the embolic risk from mobile aortic thrombus outweighs bleeding risk when heparin is properly monitored. 1, 3

• Do not use neuraxial anesthesia in the setting of therapeutic anticoagulation due to risk of epidural hematoma. 1

• Do not assume anticoagulation alone is adequate for long-term management—arrange definitive surgical consultation for the aortic thrombus after orthopedic recovery. 2, 3