Floating Thrombus on the Ascending Aorta and/or Aortic Arch: To Operate or Not to Operate? A Narrative Review

Background and Aim: Floating aortic thrombi are rare but potentially life-threatening conditions, with a high risk of systemic embolization, leading to severe complications such as stroke, mesenteric or other organ ischemia. Treatment approaches vary widely, ranging from urgent surgical resection to conservative medical management with anticoagulation, depending on the patient’s overall condition and thrombus characteristics. In this report, we present two cases of floating aortic thrombi managed with different strategies: one with surgical intervention and the other with anticoagulation. The aim is to illustrate how individualized treatment approaches are determined based on clinical presentation and the risk of embolic events. Patients and Methods: The first case concerns a 59-year-old male who presented with abdominal pain and vomiting, with subsequent imaging revealing mesenteric ischemia. Emergency laparotomy confirmed intestinal necrosis, necessitating resection of a large portion of the jejunum. Postoperatively, a floating thrombus was discovered at the junction of the ascending aorta and aortic arch, associated with cerebral embolization. The patient underwent urgent surgical intervention, including resection of the aortic thrombus and resection of the ascending aorta, with an hemiarch replacement. The second case involves an 88-year-old male who presented with bilateral paresthesia in both hands, raising suspicion of a stroke. The MRI showed acute supra- and infratentorial ischemic lesions, suggesting an embolic origin. Additional imaging revealed a floating thrombus in the ascending aorta, along with a second thrombus in the descending aorta. Given the stability of the thrombi, the absence of acute ischemic events and the patient’s age and comorbidities, which increase the risk of surgical treatment, the patient was managed conservatively with anticoagulation and close radiologic monitoring. Conclusion: These two cases highlight the varied approaches in managing floating aortic thrombi, emphasizing the importance of individualized treatment based on thrombus stability, patient comorbidities, and embolic risk. While surgical resection is warranted in high-risk cases, as demonstrated in the first patient, anticoagulation can be effective for stable thrombi and high operative risk or inoperable patients, as seen in the second case. Multidisciplinary collaboration and vigilant follow-up are critical to optimizing outcomes. Further research is necessary to refine treatment guidelines for this rare but dangerous condition.