Clinical characteristics, presentation, and outcomes in patients with thoracic aortic thrombus

Background: Thoracic aortic thrombosis (TAT) is a rare, but important cause of arterial thromboembolism (ATE). There is a paucity of published data on TAT; therefore, risk stratification and management are challenging. In this study, we evaluated risk factors, presentation, and outcomes of patients diagnosed with TAT. Methods: In this retrospective analysis, we analyzed data on all patients diagnosed with TAT by computed tomographic angiography between 2013 and 2024 at a single tertiary care center. Results: A total of 149 patients with an average age of 69.6 years (IQR 60.1–77.1) and 45.0% men were included. The most proximal thrombus location was the ascending aorta, arch, and descending aorta in 20.8%, 19.5%, and 59.7% of patients, respectively. Thrombus was attributed to atherosclerosis in 28.2% of patients, aneurysm in 32.9%, and other/unknown etiologies for the remainder of the cohort. Approximately 25% of patients presented with ATE. In a multivariable analysis, risk factors associated with ATE included age < 65 years (OR 7.9, p < 0.01), arch involvement (OR 3.7, p = 0.04), thrombus associated with atherosclerosis (OR 11.2, p = 0.042), and thrombus in nonaneurysmal/nonatherosclerotic aortas (OR 32.1, p < 0.01) in patients with CT-detected aortic thrombus. Patients with aneurysmal or atherosclerotic etiologies were less likely to be managed with anticoagulation (16% vs 61%, p < 0.01) and less likely to show thrombus regression or resolution (20% vs 68%, p < 0.01). Recurrent spontaneous embolic events occurred in three of 149 patients (median follow-up of 763 days; IQR 364–1559). Conclusions: A significant proportion of patients with thoracic aortic thrombus present with ATE. Younger patients with arch thrombosis from nonaneurysmal/nonatherosclerotic etiologies are at the highest risk of ATE. Patients with nonaneurysmal/nonatherosclerotic etiologies of aortic thrombus were more likely to be treated with anticoagulation and show thrombus regression/resolution; however, the rate of recurrent spontaneous embolic events was low.