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Objectives: Aortic mural thrombus in a nonaneurysmal, minimally atherosclerotic or normal aorta is a rare entity and an uncommon cause of arterial embolization. Both anticoagulation and aortic surgery are commonly used as primary treatment, but there is no consensus or clinical guidelines to outline the best management strategy. This systematic review compares the reported outcomes of these two management strategies.
Methods: An extensive search of the literature was conducted and all relevant publications reviewed, with individual patient data pooled in this meta-analysis. Outcome variables included persistence or recurrence of aortic thrombus, recurrence of embolization, mortality, and a composite endpoint of stroke, limb loss, and bowel resection. Chi-square test and Logistic regression analysis were used to compare groups and to find any predictors of adverse outcome.
Results: A total of 200 patients from 98 articles were enrolled (Anticoagulation N=112, SurgeryN=88). Smoking was more prevalent in the surgery group, but no other differences in demographics, comorbidities, or mode of presentation was seen between groups. The surgery group was more likely to have thrombus located in the arch, but there were no differences in mobility or size of thrombus between groups. Aortic thrombus persisted or recurred in 26.4% of the anticoagulation group and in 5.7% of the surgery group (P <.001). Recurrence of arterial embolization was seen in 25.7% of the anticoagulation group and 9.1% of the surgery group (P= .003). Mortality rates were 6.2% and 5.7% for the two groups, respectively (P =.879). Complications occurred in 27% of the anticoagulation group and 17% of the surgery group (P= .07), and major limb amputation rates were 9% and 2% for the two groups, respectively. (P=.004).Logistic regression analysis established thrombus location in the ascending aorta (OR 12.7 and 95% CI, 2.3 to 238.8) or arch (OR 18.3 and 95% CI, 2.6 to 376.7), mild atherosclerosis of the aorta (OR 2.5 and 95% CI, 1 to 6.4), and stroke presentation (OR 11.8 and 95% CI, 3.3 to 49.5) as important predictors of recurrence.
Conclusions: The results this meta-analysis seem to favor the surgical management of aortic mural thrombus in the normal or minimally diseased aorta. Anticoagulation as primary therapy is associated with a higher likelihood of recurrence and a higher incidence of limb loss.