# Floating Thrombus on the Ascending Aorta and/or Aortic Arch, to Operate or Not to Operate: Two Case Reports and a Literature Review

## TL;DR

This paper presents two cases of floating aortic thrombi and discusses the decision-making process for surgical versus medical treatment based on patient-specific factors.

## Contribution

The paper contributes two distinct case reports highlighting individualized treatment approaches for floating aortic thrombi.

## Key findings

- Surgical intervention was performed in a 59-year-old patient with a high embolic risk and mesenteric ischemia.
- Conservative anticoagulation was chosen for an 88-year-old patient with stable thrombi and high surgical risk.
- Tailored management based on embolic risk and comorbidities is essential for floating aortic thrombi.

## Abstract

Background and Aim: Floating aortic thrombi are rare but potentially life-threatening entities, associated with a high risk of systemic embolization and subsequent complications such as ischemic stroke or mesenteric infarction. Therapeutic strategies range from urgent surgical intervention to conservative medical management with anticoagulation, depending on the patient’s clinical status and thrombus morphology. This report presents two cases of floating aortic thrombi managed with distinct approaches, surgical and medical, underscoring the importance of individualized treatment guided by embolic risk and comorbidities. Patients and Methods: The first case involves a 59-year-old male presenting with abdominal pain and emesis. Imaging confirmed mesenteric ischemia, necessitating emergent laparotomy and extensive jejunal resection. Postoperative imaging identified a mobile thrombus at the ascending aorta–aortic arch junction, with evidence of cerebral embolism. The patient underwent urgent surgical thrombectomy, ascending aortic resection, and hemiarch replacement. The second case describes an 88-year-old male who presented with bilateral upper limb paresthesia. Neuroimaging revealed acute supra- and infratentorial ischemic lesions suggestive of embolic stroke. A floating thrombus was identified in the ascending aorta, with an additional thrombus in the descending thoracic aorta. Given the patient’s advanced age, comorbid conditions, and thrombus stability, a conservative approach with systemic anticoagulation and close radiologic surveillance was chosen. Conclusions: These cases illustrate the need for tailored management of floating aortic thrombi. While surgical resection remains indicated in unstable or high-risk embolic cases, anticoagulation may suffice for stable lesions in patients with elevated surgical risk. Further studies are needed to establish standardized therapeutic guidelines.