If the patient has a sign of peripheral embolus, I am treating these patients 

If no evidence of distal embolization is found, I manage these patients with anticoagulation with interval imaging follow up.  Typically I image these patients at 1 month following initial diagnosis and if thrombus propagation or abnormal remodeling is noted, consider treatment. 

I generally manage with anticoagulation and imaging if no complicatons (embolisms) occur. Strict imaging (1 monts and every six months if no regression) may be needed.

Without signs of embolisation, conservative medical therapy would be my choice: anticoagulation with coumarine and statine for 3 months if you consider that the thrombus is fresh or that the peduncular portion could dislocate and embolise, (control CT Scan after 3 months: if no growth, no signs of embolisation) - thereafter only aspirin and statine. Curative endovascular therapy (covered stent) would be indicated only when symptoms due to embolisation or true aneurysmatic development occur. Based on the literature, parietal thrombus of the normal thoracic aorta (no significant kinking that could cause turbulent flow) embolises very rarely.

I would start anticoagulation and make a follow-up CT after 3 month

Without evidence of embolisation, my choice is medical therapy and imaging, each 03 months endovascular procedures , only if symptoms occured.

Without previous evidence of embolism, anticoagulation with heparin (then coumadine) and imaging (CT) until regression.

In case of embolism (s), covered stent of thoracic aorta

Differently from the treatement of a shaggy aorta, in which anticoagulation may cause a distal embolic spread and surgical approach (endovascular/open) could be considered the first choice, in case of asymptomatic and isolated thrombus in the descending aorta I whould use a conservative, medical treatement with anticoagulation and a CT scan control after 3 months if no complication occurs. Otherwise (in case if distal embolization) the use of a covered stent/graft could be the right choice. Think also about the possible ethiopatology: could be a sign of a rare paraneoplastic syndrome?? Coagulation-related problem?? Infection??

Thank you to all for the nice discussion.

I completely agree with medical treatment and strict follow up in asymptomatic patients. Surgical and/or endovascular solutions could be reserved in cases of distal embolization. What I found interesting in my case is that this patient was “not treated” for over one month: initially managed by a not-vascular center, no therapy modifications were applied. The patient went to our attention with a CT scan of the thorax performed for suspect of pulmonary embolism: no emboli were founded but a mural thrombus in a NAADTA was present. The patient was treated until our observation with aspirin and statin, and he was asymptomatic. We decided to repeat a CT scan of thoraco-abdominal aorta, which revealed a stable situation, with not regression or progression of the thrombus and without any sign of distal embolization.

Do you think is still recommended and oral anticoagulation? If yes, how long do you think it should be maintained? Until a complete resolution? Otherwise could be a role for antiplatelet alone?

Another key point in my opinion is the etiology: first of all I would like to exclude malignant diseases or coagulation disorders. What do you think about it? Have you any experience with a thrombus in a NAADTA as first presentation of such diseases?

I had a patient with A subacute left lower limb ischemia due to an anterior tibial artery embolic occlusion with no plantar vessel (the embolic spread probably caused first an asymptomatic slow degradation of other distal and plantar vessels) treated in onother centre with sodic heparine. He came to my observation with successive acute limb ischemia and a total thrombotic occlusion of left ilio-fem-pop and distal axis. In emergency I managed it with fogarty thromboembolectomy but (under sodic heparine infusion) he had onother fem-pop occlusion after few days... A total body CT scan revealed two primitive pulmonary lesions (both right and left side) with surrenal, bone and limphonodal repetitions (in mediastinum and abdomen); he had also a thrombus in the aortic arch...With signs of embolization also at renal and rat's levels. The limb was lost I need to perform a major amputation after few days another embolic spread caused a massive bowel ischemia with a tragic exitus of a 55 years old man.

i agree with medical treatment in asymptomatic patients ; but after embolization and surgical treatment of acute ischemia of visceral arteries or lower limbs the mural thrombus may disappear at CT control. In these cases the diagnosis is difficult . I think that a more aggressive endovascular treatment may be advised in young patients with large peduncolar mural thrombus.

Many of these originate in the stump of the ductus and are grossly mobile. They usually are discovered because of embolic presentation. Many can be very large. We resect these by open operation.

The ones that are just layered along the more distal aortic wall we watch with serial CT scans. We do not really know a cause for these.