Ascending Aortic Thrombus in a patient presenting with Mesenteric Ischemia

Introduction: Ascending aortic thrombus (AAT) is a rare presentation with potential for catastrophic complications including cerebral, visceral, and peripheral emboli. Patients with this condition usually present after an embolic event, often with long-term sequelae. Case: A 54-year-old male with past medical history of prior ischemic strokes, congestive heart failure with reduced ejection fraction (EF 22%), coronary artery disease, hypertension, hyperlipidemia, and tobacco use disorder, presented to the ED with lower abdominal pain that was abrupt, 10/10, crampy, with nausea and vomiting. Abdominal exam revealed mild hypogastric tenderness out of proportion to stated discomfort. Initial labs revealed WBC count of 21,300 cells/mm3, troponin peaking at 5.73 ng/ml, and lactate of 2.8 mmol/L rising to 7 mmol/L within 6 hours. CT angiogram revealed thrombosis in the superior mesenteric artery (SMA) and a prominent thrombus in the ascending aorta, likely embolic source. Transthoracic echocardiogram revealed an EF of 5-10%. Patient was taken for emergency exploratory laparotomy where SMA thrombectomy and patch angioplasty was successfully performed. Hypercoagulability workup was negative. Due to extensive comorbidities, patient was determined to be a poor candidate for a thrombectomy of the ascending aorta, and anticoagulation was initiated. Discussion: The case is a rare presentation of an AAT with mesenteric ischemia. Chronic heart failure is the suspected etiology, but we were not able to find an association between heart failure and AAT to date. AAT is ideally managed with surgical intervention. Systemic thrombolysis and anticoagulation remain an option, with only few cases reporting successful outcomes.