Do Not Delay Surgery for Incidental Aortic Arch Mural Thrombus
Surgery should proceed within 24-48 hours as recommended for all hip fractures, without delay for the incidental aortic arch mural thrombus finding. The thrombus is not a contraindication to surgery and does not warrant postponement, as delaying hip fracture surgery significantly increases mortality and morbidity 1.
Rationale for Proceeding to Surgery
Evidence Against Surgical Delay
- Delaying surgery beyond 48 hours from admission is associated with increased mortality, particularly if the delay is prolonged 1, 2.
- Surgical delay beyond 48 hours increases morbidity including pressure sores, pneumonia, and thromboembolic complications 1, 2.
- There is no evidence that delaying surgery to allow pre-operative physiological stabilization improves outcomes 1, 2.
- A 2015 study demonstrated that surgery within 12 hours improved 30-day survival compared with surgery after 12 hours 3.
The Aortic Thrombus Does Not Change Management
- The mural thrombus is an incidental finding on CT scan and represents a marker of atherosclerotic disease rather than an acute surgical emergency 4.
- No guidelines exist that recommend delaying orthopedic surgery for incidental aortic mural thrombus 1.
- The thrombus is non-mobile (as stated in your question), which significantly reduces embolic risk during the perioperative period 4, 5.
Acceptable Reasons to Delay Hip Fracture Surgery
The following conditions warrant brief delay, but aortic mural thrombus is not among them 1, 2:
- Hemoglobin <8 g/dL requiring transfusion
- Severe electrolyte abnormalities (hypokalaemia, hypomagnesaemia)
- Uncontrolled diabetes with ketoacidosis
- Uncontrolled or acute onset left ventricular failure
- Correctable cardiac arrhythmia with ventricular rate >120/min
- Chest infection with sepsis
- Reversible coagulopathy (INR >2.0)
Perioperative Management Approach
Immediate Actions
- Proceed with standard preoperative optimization protocol including monitoring, IV fluids, analgesia, and pressure care 1, 6.
- Ensure multidisciplinary coordination between orthogeriatrics, anesthesia, and surgery teams 1, 6.
- Target surgery within 24-48 hours from admission 1, 2.
Anesthetic Considerations
- Either spinal or general anesthesia is appropriate 1.
- Consider invasive blood pressure monitoring given the patient's atherosclerotic disease burden 1, 7.
- Maintain hemodynamic stability to minimize risk of embolic events during positioning and manipulation 1.
Anticoagulation Strategy
- Initiate or continue antiplatelet therapy postoperatively for the aortic thrombus 4.
- Standard thromboprophylaxis for hip fracture should be administered (fondaparinux or low molecular weight heparin) 6.
- Consult cardiology or vascular surgery postoperatively for long-term management of the aortic thrombus, but do not delay surgery for this consultation 4, 5.
Common Pitfall to Avoid
Do not delay surgery for additional cardiac imaging or specialty consultations regarding the aortic thrombus 7, 8. A 2004 audit demonstrated that implementing echocardiography requirements for cardiac assessment delayed hip fracture surgery by 4-8 days without altering management 8. The same principle applies to the incidental aortic finding—it should not delay definitive fracture treatment.
Post-Surgical Management
- Arrange outpatient cardiology or vascular surgery follow-up for the aortic mural thrombus 5.
- Long-term anticoagulation or antiplatelet therapy decisions can be made after the patient recovers from hip fracture surgery 4, 5.
- The patient will likely require lifelong antiplatelet therapy at minimum given the atherosclerotic burden 4.