The evidence on the topic of floating thrombi in ascending aorta is very limited and dispersed. According to the International Guidelines (2014 ESC Guidelines on the diagnosis and treatment of aortic diseases; Section 9 Atherosclerotic lesions of the aorta; Chapter 9.2 Mobile aortic thrombosis) consensus is based on experts’ opinion (level of evidence C) and every case becomes peculiar and must be discussed in a Heart Team [
1]. Kalangos et al. put the accent on differential diagnosis which no longer represents a challenge thanks to ever more advanced diagnostic imaging [
4]. Meanwhile the pathophysiological mechanism of thrombi still remains unclear, as patients frequently do not suffer from coagulopathies, immunological disorders or malignancies. In non-aneurysmatic, non-atherosclerotic vessels and in absence of a clear etiology Behcet’s disease can be suggested as a possible cause, particularly among countries around Mediterranean Sea, but this was not our case. According to operative findings of a three-sites aortic wall insertion, we decided to replace that portion of aortic wall. Although no real atheroma was found and excised aortic wall appeared normal on histological and immunological examinations, we strongly recommend replacement of the involved portion of aorta, in order to prevent recurrences. On the other hand this could increase operative risk, depending on location of thrombus particularly in proximity of aortic arch. While conservative medical treatment certainly represents a cornerstone of primary approach in asymptomatic patients, management becomes demanding in presence of symptoms or distal embolism. Embolisms (e.g. cerebral) could significantly limit the surgical options. A few cases have shown that a conservative approach with anticoagulants represents a viable option [
5,
6]. However Moris et al. suggested the strategy should be chosen based on peculiar characteristics of thrombus like its location, mobility, morphology, persistence of symptoms under anticoagulants and high risk of recurrence [
7]. While the dimensions of the thrombus are never considered as main criterion, the location of thrombus strongly affects the possible surgical strategies. Thrombus removal under circulatory arrest and deep hypothermia has been proposed [
3] as well as with normothermic aortic cross clamping [
4]. In our case, thrombus was located in the distal ascending aorta, with inherent concerns. Arterial peripheral cannulation (e.g. femoral artery or right subclavian artery) could represent a valid option, minimizing manipulation of the aorta. Live epi-aortic echocardiography enabled to define the exact position and dimensions of the thrombus. These echo findings added information essential to determine the safe cannulation site.
Our patient was discharged from hospital on vitamin K antagonist for three months owing to previous renal embolism. After this period Aspirin has been started lifelong. A six months follow-up CT-scan showed no signs of thrombi. Since secondary prophylaxis still represents a debating issue, we propose an effective and feasible solution to treat thrombi in ascending aorta. In a field where no precise indications are available, we aim to contribute to develop specific guidelines and flowcharts that help consultants in the decision making process, ensuring the best care for patients.