Authors

• Ana Šutalo — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-7644-6362
• Petra Grubić Rotkvić — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-2587-1932
• Mislav Puljević — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0003-1477-2581
• Marija Brestovac — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0003-1542-2890
• Ivana Jurca — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-0607-3361
• Majda Vrkić Kirhmajer — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-1340-1917

Keywords

free-floating thrombus, aorta, anticoagulation

DOI

Full Text

**Introduction**: A free-floating thrombus is a mobile aortic thrombus that appears to float freely, while being attached at one end to the aortic wall. Although rare, it has 73% risk of embolic events (1). Etiologies include atherosclerosis, acute aortic syndrome, and hypercoagulability. Surgical thrombectomy and thrombolysis are the primary treatments in the acute setting (2), but clear management recommendations are lacking. Treatment depends on the clinical picture, patient condition and thrombus size and location. **Case series**: We present three cases of free-floating aortic thrombi from 2021 to 2023. A 68-year-old male was hospitalized due to COVID19 pneumonia. Computed tomography angiography (CTA) of pulmonary artery revealed a floating thrombus in the distal ascendent aorta, extending throughout the aortic arch. Spleen and renal infarction coexisted. A 65-yeard-old male presented with upper left abdominal pain. Computed tomography (CT) confirmed spleen infarction. Further imaging revealed floating thrombi in ascendent aorta. Laboratory findings were positive for ANA, anti dsDNA, and anti U1RNP raising suspicion for collagenosis or vasculitis. A 70-year-old female was admitted with critical limb threatening ischemia. Laboratory testing revealed leukocytosis and thrombocytosis. CTA showed a floating thrombus in the infrarenal aorta extending into both common iliac arteries (**Figures 1** and **2**Figure 2). A JAK2 positive myeloproliferative neoplasm was diagnosed. All patients were initially treated with low molecular weight heparin. The first patient was discharged on warfarin and two others on rivaroxaban. The third patient was additionally prescribed acetylsalicylic acid. Follow-up CTA showed complete resolution of thrombi in first two patients and complete resorption of the thrombi in iliac arteries and partial resorption in the infrarenal aorta for the third one (**Figures 3** and **4**Figure 4). All three patients underwent a full clinical recovery. FIGURE 1. Computed tomography angiography showing floating thrombi in the infrarenal aorta of a 70-year-old female. FIGURE 2. Floating thrombi extending into both common iliac arteries in the same patient. FIGURE 3. Follow-up scan showing resolution of thrombi in common iliac arteries. FIGURE 4. Only partial resorption of thrombi in the infrarenal aorta of the same patient. **Conclusion**: A conservative approach involving anticoagulation and management of cardiovascular risk factors can be effective regardless of underlying etiology.

Literature

1. Verma H, Meda N, Vora S, George RK, Tripathi RK. Contemporary management of symptomatic primary aortic mural thrombus. J Vasc Surg. 2014 December;60(6):1524–34. https://doi.org/10.1016/j.jvs.2014.08.057
2. Oki N, Inoue Y, Kotani S. Free-floating thrombus of the aorta: 3 case reports. Surg Case Rep. 2021 June 10;7(1):141. https://doi.org/10.1186/s40792-021-01230-7