Dear Hugo,

first of all you are right about there being not much data available on free floating aortic thrombi. However, in my oppinion the first move always should be therapeutic anticoagulation, as such thrombi need to be treated, even if no embolic event has happened so far. Wether or not thrombocytic aggregation inhibitors (ASS etc.) should be added, I do not know. Some case reports have been published with that strategy, one paper including the retrospective analysis of 37 patients. I have included the pubmed link below. The second link is leading to my search results which lead to 41 hits - not all directly linked with the problem.

As I said, if it was me, I would rather want to be anticoagulated instead of operated on, although anticoagulation could lead to emboli due to weakening of the clot - because at the point when there are thrombi in my aorta, more are due to come, as the intima will probably be horribly damaged in any case.

http://www.ncbi.nlm.nih.gov/pubmed/25173962

http://www.ncbi.nlm.nih.gov/pubmed/?term=free+floating+aortic+thrombus

Dear Hugo Rodrigues,

That`s a very good question!

I agree with Julian Strobel 100%.

First of all good surveillance and therapeutic anticoagulation if such thrombi need to be treated.

I agree with other previous reply. First stage surveillance and anticoagulation.In case of no optimal results I consider TEVAR as good option

I agree with Julian about anticoagulation although there are conflicting reports in literature.

Journal of vascular Surgery; Epub Ahead of print September 2014

 http://dx.doi.org/10.1016/j.jvs.2014.08.057

Symptomatic PAMT is an uncommon but important source of noncardiogenic embolus. It appears to occur more frequently in young women. Endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with either stent grafts or closed-cell metal stents. When thrombus is located adjacent to visceral vessels, it should be managed with an open trapdoor thromboembolectomy

I think the first option is aggressive anticoagulation if patient is asymptomatic with close monitoring with TEE. I' ve seen 2 patient treated in this way with good result. TEVAR shows a theoretical embolic potential larger than a conservative approach. Open surgery is only for peculiar cases of associated lesion. Of course we ' ve to consider a second stage of treatment if the thrombus is due to an atherosclerotic burden of the aorta rather then to a coagulation disorder.

Open surgery must be the first option. Rev. Esp. Cardiol. 2009;62:576-7

It is rare pathology, mostly in young patients, and should be differentiated from the even rarer angiosarcomas. In case it is located in the aortic arch emboli may cause severe brain infarction, so urgent removal is indicated in these cases and most probably should be open surgery. In my opinion in young and able patients open surgery is safer, even in cases of more distal mural aortic thrombi. When open surgery seems contraindicated endovascular options should be considered next to conservative treatment with anticoagulant.

Dear Antonio,

I aggree that if anticoagulation is not successful, surgery is essential. However, in the Letter you quoted the colleagues stated: " The patient was surgically

treated due to the persistence of the mass despite

intravenous treatment with heparin." Reading this, I would think that they first tried anticoagulation and then went for surgery. Is that right?

Thank you all for your answers. please feel free to give your opinion on the case:

male, 63 y, previous prostate cancer. Current AAA with 60mm. CT study shows this image on the descending thoracic aorta:

He as moderate surgical risk for open surgery and i would prefer to do an EVAR for the AAA. Would you prefer open surgery, regarding the risk of guidewire manipulation? would you do a EVAR despite the lesion, while full anti-coagulated? would you cover the lesion with a preemptive small TEVAR? 

Dear Hugo,

This case:

TEVAR NOT TOO SHORT. 

in my opinion open approach is not completely without risks.

anticoagulation is the first approach and second TEVAR

Anticoagulation

Anticoagulation. TEVAR only for selected symptomatic cases.