Case Presentation: Our patient is a 51-year-old male with PMHx of tobacco abuse who presented to the emergency room (ER) with left flank pain for 1 month. He was involved in a motor vehicle collision while driving his motorcycle four weeks ago. He initially presented to an urgent care for pain where he was found to have microscopic hematuria on urinalysis. Computed Tomography Angiography (CTA) of the abdomen and pelvis was performed on presentation. The CTA showed a mural thrombus present within the lumen of the infra-renal abdominal aorta. This resulted in narrowing of the opacified lumen of the distal abdominal aorta and right common iliac artery without aneurysmal dilatation or dissection (Images 1 and 2). He was started on a heparin infusion and risk factors for mural thrombi were evaluated. His Hemoglobin A1C was 5.7, his fasting lipid profile showed a low-density lipoprotein (LDL) level of 173, and he smoked one-half pack of cigarettes daily. Our patient denied a personal and family history of thrombi or hypercoagulable states. No reported malignancy, inflammatory bowel disease and no previously or currently prescribed medications. On day 2, our patient endorsed improved flank pain and otherwise had no complaints. He completed 24 hours of heparin drip therapy and was transitioned to a direct oral anticoagulant (DOAC) for treatment of the thrombus. Our patient was prescribed Atorvastatin 40 mg daily for his hyperlipidemia. For our patient’s DOAC he received Rivaroxaban including the loading dose of 15 mg twice daily for 21 days and 20 mg daily after. Anti-coagulation was discontinued after 6 months with no complications. No surgical intervention was required. Our patient continues to be followed by vascular surgery who is currently recommending lifestyle modifications. Our patient has stopped smoking and is compliant with his atorvastatin.
Discussion: Mural thrombi are thrombi that attach to the walls of blood vessels and are a rare phenomenon most commonly associated with either hypercoagulable states, inflammation, infection or familial history (1). Oftentimes, these thrombi are incidentally found on imaging and have no acute symptoms. However, the greatest concern comes from their risk of embolization causing stroke or limb ischemia. Currently there does not appear to be a clear consensus or clinical guideline as to whether surgical management or medical anticoagulation are better for the treatment of aortic mural thrombi. In previous case reports and analysis, the anticoagulation was completed with warfarin (2). There appears to be no significant literature regarding use of direct oral anticoagulants in this patient population; most likely due to both rarity of our condition and the recency of data demonstrating the effectiveness of DOACs in multiple thrombotic disease states. There continue to be specific cases where warfarin is still the preferred agent such as with mechanical valves and left ventricular thrombi. Our case is interesting due to the presentation of the rare condition but also for the successful management of the thrombi using Rivaroxaban, a DOAC, as an anti-coagulant with no complication or surgical intervention required after 6 months.
Conclusions: Mural thrombi are a rare phenomenon which can be seen affecting the aorta with no exact clinical guideline for management at this time. One treatment model consists of anticoagulation to prevent further thrombus growth. As direct oral anticoagulants become more common, we may see more information in the literature regarding their use in these scenarios.
