Floating Thrombus in the Ascending Aorta Presenting with Recurrent Embolic Events: A Case Report Emphasizing Surgical and Diagnostic Considerations

Floating Thrombus in the Ascending Aorta Presenting with Recurrent Embolic Events: A Case Report Emphasizing Surgical and Diagnostic Considerations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Floating Thrombus in the Ascending Aorta Presenting with Recurrent Embolic Events: A Case Report Emphasizing Surgical and Diagnostic Considerations Hironari No, Hiroki Kato, Masaki Kitazawa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7134535/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: A floating thrombus in the ascending aorta is a rare but potentially life-threatening condition that may present as cerebral or peripheral arterial embolism. Given the limited number of reports, optimal treatment strategies remain unclear. Case presentation: A 49-year-old male presented with acute right lower extremity ischemia during sleep. Emergent thrombectomy of the right common femoral artery was performed, and subsequent imaging revealed a floating thrombus in the ascending aorta. Notably, the patient had suffered a cryptogenic cerebral infarction two months earlier. Elective ascending aortic replacement was undertaken. The thrombus and affected aortic wall segment were excised and replaced with a prosthetic graft. The patient's postoperative course was uneventful. Conclusions: This case underscores the importance of considering aortic thrombus in patients with recurrent embolic events of undetermined origin. Surgical resection is advisable not only to prevent recurrence but also to exclude malignancy. Detailed intraoperative decision-making regarding perfusion strategy and aortic clamping should be highlighted, especially in rare cases such as this. Floating thrombus ascending aorta embolic stroke of undetermined source peripheral arterial embolism ascending aortic replacement Figures Figure 1 Figure 2 Figure 3 Introduction Floating thrombus in the ascending aorta is a rare pathological entity often identified incidentally in the setting of embolic events. Although various treatment modalities—ranging from anticoagulation to surgical resection—have been reported, no consensus exists on the optimal management. Surgical indications remain empirical, largely guided by thrombus size, mobility, and clinical context. We report a case of a floating thrombus in the ascending aorta presenting with recurrent embolic events and describe the surgical approach and decision-making process in detail. Case Presentation A 49-year-old man with a history of cryptogenic cerebral infarction presented with sudden-onset right leg pain during sleep. Computed tomography angiography (CTA) revealed an occlusive thrombus in the right common femoral artery, which was removed emergently. Histology confirmed the specimen to be an organized thrombus. The patient had experienced a cerebral infarction two months earlier, at which time transthoracic echocardiography (TTE), carotid ultrasound, and non-contrast CT failed to identify an embolic source, and anticoagulation therapy had been initiated. Upon this admission, contrast-enhanced CTA revealed a floating mass attached to the posterior wall of the ascending aorta (Fig. 1 ). Further evaluation with positron emission tomography-computed tomography (PET-CT) excluded malignancy (Fig. 2 ). Laboratory tests showed no abnormalities in protein C, protein S, or antithrombin III levels, and antiphospholipid antibodies were negative. Blood cultures were also negative. A diagnosis of floating thrombus was made. Given the recurrent embolic events and the risk of malignancy, surgical resection was planned. Written informed consent was obtained. Cardiopulmonary bypass (CPB) was established via central cannulation of the aortic arch and right atrium, with the patient cooled to 34°C. Intraoperative epi-aortic echocardiography was utilized to determine the safe clamping site, avoiding inadvertent manipulation of the thrombus. Cross-clamping was deemed feasible without the need for circulatory arrest. The involved segment of the ascending aorta was resected along with the thrombus and replaced with a prosthetic graft. Histological analysis confirmed a thrombus composed of fibrin, red blood cells, and neutrophils with features of organization. The aortic wall showed mild atherosclerotic changes without neoplastic features (Fig. 3 ). The postoperative course was uneventful, and the patient was discharged on postoperative day 13. Oral aspirin was initiated, as no arrhythmias or other embolic sources were identified. Discussion A floating thrombus in the ascending aorta is a rare but clinically significant condition, especially when it occurs in a morphologically normal aorta. Most cases are diagnosed after embolic events such as cerebral infarction or peripheral arterial occlusion, although incidental detection has also been reported [ 1 , 2 ]. In our case, the patient presented with acute right femoral artery occlusion and had a prior history of cryptogenic cerebral infarction, prompting a detailed search for the embolic source. Contrast-enhanced CT and intraoperative findings confirmed a pedunculated, mobile thrombus in the ascending aorta without underlying aortic aneurysm or dissection. No malignancy or hypercoagulable state such as antiphospholipid syndrome or cancer-associated thrombosis was identified. This aligns with previous studies showing that floating thrombi can form in otherwise normal aortas, possibly due to subtle endothelial injury or hemodynamic factors [ 3 ]. Conservative management with anticoagulation has been attempted in some cases, but carries a significant risk of recurrent embolism or limb loss [ 4 ]. Surgical resection is generally favored when the thrombus is large, mobile, or associated with embolic events [ 5 ]. In our patient, FDG-PET showed no uptake in the thrombus, but due to its pedunculated morphology and prior embolic history, we opted for ascending aortic replacement with a prosthetic graft. This approach avoids the risk of incomplete resection and enables histopathological confirmation, helping to rule out neoplastic etiologies [ 6 ]. Review of the literature confirms that the ascending aorta is involved in only about 8% of aortic thrombus cases [ 7 ]. Surgical options range from thrombectomy alone to full aortic replacement, with the latter offering a lower recurrence rate when thrombus adherence to the wall is suspected [ 8 ]. In patients with autoimmune conditions or those receiving steroids or chemotherapy, systemic inflammation and prothrombotic states may further increase the risk of thrombus formation [ 9 , 10 ]. Our case adds to the growing body of evidence suggesting that surgical resection with aortic replacement should be considered in patients with mobile ascending aortic thrombi and a history of embolic events, even in the absence of overt aortic disease. The patient recovered uneventfully and remained free from recurrence at one-year follow-up, reinforcing the efficacy of definitive surgical treatment. Conclusion Floating thrombus in the ascending aorta is a rare but serious clinical entity that can lead to devastating embolic events. In patients presenting with recurrent embolism of undetermined source, ascending aortic thrombus should be considered even in the absence of aneurysm or significant atherosclerosis. While anticoagulation may be considered in select cases, surgical treatment provides both diagnostic confirmation and definitive therapy. In our case, ascending aortic replacement was performed with favorable postoperative outcomes and no recurrence at one year. This case highlights the importance of comprehensive embolic source evaluation and supports early surgical intervention in high-risk patients. Abbreviations CPB cardiopulmonary bypass CTA Computed tomography angiography CT computed tomography ESC European Society of Cardiology PET-CT positron emission tomography-computed tomography TTE transthoracic echocardiography NSR normal sinus rhythm RBC red blood cells Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patient for surgical treatment and inclusion in this case report. Consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. Funding No funding was received for this study. Author Contribution H.N. and H.K. performed the surgery. H.N., H.K., and M.K. managed the postoperative care. H.N. conceptualized the study, prepared the figures, and wrote the manuscript. All authors reviewed and approved the final version. References Machleder HI, Takiff H, Lois JF, Holburt E. Aortic mural thrombus: an occult source of arterial thromboembolism. J Vasc Surg. 1986;4(5):473–478. Ito Y, Funatsu T, Kamata S, Yagihara T. A case of asymptomatic thrombus in the ascending aorta. Jpn J Cardiovasc Surg. 2019;48(1):43–46. Fayad ZY, Semaan E, Fahoum B, et al. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282–290. Pagni S, Trivedi J, Ganzel BL, et al. Thoracic aortic mobile thrombus: is there a role for early surgical intervention? Ann Thorac Surg. 2011;91(6):1875–1881. Wang B, Ma D, Cao D, Man X. Huge thrombus in the ascending aorta: a case report and literature review. J Cardiothorac Surg. 2019;14(1):157. Haida H, Inoue Y, Kawajiri H, Suzuki S. Rod-shaped giant floating thrombus in a normal ascending aorta. Eur J Cardiothorac Surg. 2015;47(3):582. Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713–719. Geana RC, Nayyerrani R, Dragulescu RP, et al. COVID-19-related floating thrombus in the ascending aorta: a case report. In Vivo. 2023;37(5):2381–2386. Sato T, Mishima T, Sato H, et al. A case of thrombus formation in the ascending aorta causing acute myocardial infarction. Jpn J Cardiovasc Surg. 2019;48(3):197–201. Lee KY, Kim SJ, Choi CH, et al. Rod-shaped giant floating thrombus in a nonaneurysmal, nonatherosclerotic ascending aorta. Ann Thorac Surg. 2014;98(6):e139–e141. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Apr, 2026 Reviews received at journal 01 Apr, 2026 Reviewers agreed at journal 26 Mar, 2026 Reviews received at journal 23 Jul, 2025 Reviewers agreed at journal 23 Jul, 2025 Reviewers invited by journal 22 Jul, 2025 Editor assigned by journal 21 Jul, 2025 Submission checks completed at journal 21 Jul, 2025 First submitted to journal 15 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7134535","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":489937476,"identity":"57809549-ef9e-4ee7-8727-a1c2deb0f76b","order_by":0,"name":"Hironari No","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYFACHoYDDAwS9W3szUCaQUKGWC02jP08xxJAWniI0gIEaYwzZ+QYwLl4gTkD78HDFRWHmQ3OnPn86kaNBQ8D++GjG/BpsWzgSzh45sxhNoPjvdusc44BHcaTlnYDnxaDAzwGBxvbDvMYnDm7zTiHDahFgseMKC0SBjdynhnn/CNeS5qB5Iwc5se5bcRoATrpYMMZmwR+nmNmzLl9EjxsBP1yvMf4Y0OFRAIbe/Pjzznf6uT42Q8fw6uFgRnBZJMAk3iVo+v+QIrqUTAKRsEoGDkAAH94SmJW91LwAAAAAElFTkSuQmCC","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hironari","middleName":"","lastName":"No","suffix":""},{"id":489937477,"identity":"e71adb7a-035b-43e0-b643-f8c6647efe18","order_by":1,"name":"Hiroki Kato","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hiroki","middleName":"","lastName":"Kato","suffix":""},{"id":489937478,"identity":"7d218c49-b735-4310-a68e-ff3938191734","order_by":2,"name":"Masaki Kitazawa","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masaki","middleName":"","lastName":"Kitazawa","suffix":""}],"badges":[],"createdAt":"2025-07-16 00:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7134535/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7134535/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87551190,"identity":"29d1a576-04ec-4864-ab7d-52541087413b","added_by":"auto","created_at":"2025-07-25 06:21:15","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":339150,"visible":true,"origin":"","legend":"\u003cp\u003eCTA axial (A) and coronal (B) images showed a mobile thrombus in ascending aorta.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7134535/v1/3f0895143626d025cb0a178f.jpeg"},{"id":87552582,"identity":"459ed9ea-753c-4867-a8bd-31382d795710","added_by":"auto","created_at":"2025-07-25 06:29:15","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":476803,"visible":true,"origin":"","legend":"\u003cp\u003ePET-CT showed no abnormal uptake, indicating the thrombus was not malignant.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7134535/v1/a7ad7ef87422ec4ed21f8347.jpeg"},{"id":87551185,"identity":"5cef5c6a-cd47-4a12-b73d-4f8374a1d56a","added_by":"auto","created_at":"2025-07-25 06:21:15","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1010746,"visible":true,"origin":"","legend":"\u003cp\u003eThe thrombus is composed mainly of fibrin, with infiltration of platelets, red blood cells, and neutrophils. The thrombus and the thrombus of the aortic attachments show organizing features such as infiltration of fibroblasts and intravascular cells. There are no neoplastic changes.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7134535/v1/5e90037b0b8078ac0d574afb.jpeg"},{"id":87554862,"identity":"19f14578-83dd-4c95-94ec-084dde62a8ae","added_by":"auto","created_at":"2025-07-25 06:53:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2131288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7134535/v1/387cefe8-909e-4f37-8d87-37b1cac9beb8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Floating Thrombus in the Ascending Aorta Presenting with Recurrent Embolic Events: A Case Report Emphasizing Surgical and Diagnostic Considerations","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFloating thrombus in the ascending aorta is a rare pathological entity often identified incidentally in the setting of embolic events. Although various treatment modalities\u0026mdash;ranging from anticoagulation to surgical resection\u0026mdash;have been reported, no consensus exists on the optimal management. Surgical indications remain empirical, largely guided by thrombus size, mobility, and clinical context. We report a case of a floating thrombus in the ascending aorta presenting with recurrent embolic events and describe the surgical approach and decision-making process in detail.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 49-year-old man with a history of cryptogenic cerebral infarction presented with sudden-onset right leg pain during sleep. Computed tomography angiography (CTA) revealed an occlusive thrombus in the right common femoral artery, which was removed emergently. Histology confirmed the specimen to be an organized thrombus. The patient had experienced a cerebral infarction two months earlier, at which time transthoracic echocardiography (TTE), carotid ultrasound, and non-contrast CT failed to identify an embolic source, and anticoagulation therapy had been initiated.\u003c/p\u003e\u003cp\u003eUpon this admission, contrast-enhanced CTA revealed a floating mass attached to the posterior wall of the ascending aorta (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Further evaluation with positron emission tomography-computed tomography (PET-CT) excluded malignancy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Laboratory tests showed no abnormalities in protein C, protein S, or antithrombin III levels, and antiphospholipid antibodies were negative. Blood cultures were also negative. A diagnosis of floating thrombus was made. Given the recurrent embolic events and the risk of malignancy, surgical resection was planned. Written informed consent was obtained.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eCardiopulmonary bypass (CPB) was established via central cannulation of the aortic arch and right atrium, with the patient cooled to 34\u0026deg;C. Intraoperative epi-aortic echocardiography was utilized to determine the safe clamping site, avoiding inadvertent manipulation of the thrombus. Cross-clamping was deemed feasible without the need for circulatory arrest. The involved segment of the ascending aorta was resected along with the thrombus and replaced with a prosthetic graft. Histological analysis confirmed a thrombus composed of fibrin, red blood cells, and neutrophils with features of organization. The aortic wall showed mild atherosclerotic changes without neoplastic features (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe postoperative course was uneventful, and the patient was discharged on postoperative day 13. Oral aspirin was initiated, as no arrhythmias or other embolic sources were identified.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA floating thrombus in the ascending aorta is a rare but clinically significant condition, especially when it occurs in a morphologically normal aorta. Most cases are diagnosed after embolic events such as cerebral infarction or peripheral arterial occlusion, although incidental detection has also been reported [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In our case, the patient presented with acute right femoral artery occlusion and had a prior history of cryptogenic cerebral infarction, prompting a detailed search for the embolic source.\u003c/p\u003e\u003cp\u003eContrast-enhanced CT and intraoperative findings confirmed a pedunculated, mobile thrombus in the ascending aorta without underlying aortic aneurysm or dissection. No malignancy or hypercoagulable state such as antiphospholipid syndrome or cancer-associated thrombosis was identified. This aligns with previous studies showing that floating thrombi can form in otherwise normal aortas, possibly due to subtle endothelial injury or hemodynamic factors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConservative management with anticoagulation has been attempted in some cases, but carries a significant risk of recurrent embolism or limb loss [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Surgical resection is generally favored when the thrombus is large, mobile, or associated with embolic events [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our patient, FDG-PET showed no uptake in the thrombus, but due to its pedunculated morphology and prior embolic history, we opted for ascending aortic replacement with a prosthetic graft. This approach avoids the risk of incomplete resection and enables histopathological confirmation, helping to rule out neoplastic etiologies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eReview of the literature confirms that the ascending aorta is involved in only about 8% of aortic thrombus cases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Surgical options range from thrombectomy alone to full aortic replacement, with the latter offering a lower recurrence rate when thrombus adherence to the wall is suspected [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In patients with autoimmune conditions or those receiving steroids or chemotherapy, systemic inflammation and prothrombotic states may further increase the risk of thrombus formation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur case adds to the growing body of evidence suggesting that surgical resection with aortic replacement should be considered in patients with mobile ascending aortic thrombi and a history of embolic events, even in the absence of overt aortic disease. The patient recovered uneventfully and remained free from recurrence at one-year follow-up, reinforcing the efficacy of definitive surgical treatment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFloating thrombus in the ascending aorta is a rare but serious clinical entity that can lead to devastating embolic events. In patients presenting with recurrent embolism of undetermined source, ascending aortic thrombus should be considered even in the absence of aneurysm or significant atherosclerosis. While anticoagulation may be considered in select cases, surgical treatment provides both diagnostic confirmation and definitive therapy. In our case, ascending aortic replacement was performed with favorable postoperative outcomes and no recurrence at one year. This case highlights the importance of comprehensive embolic source evaluation and supports early surgical intervention in high-risk patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCPB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecardiopulmonary bypass\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCTA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed tomography angiography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eESC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEuropean Society of Cardiology\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePET-CT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epositron emission tomography-computed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTTE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003etransthoracic echocardiography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNSR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003enormal sinus rhythm\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ered blood cells\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patient for surgical treatment and inclusion in this case report.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003e Written informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eH.N. and H.K. performed the surgery. H.N., H.K., and M.K. managed the postoperative care. H.N. conceptualized the study, prepared the figures, and wrote the manuscript. All authors reviewed and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMachleder HI, Takiff H, Lois JF, Holburt E. Aortic mural thrombus: an occult source of arterial thromboembolism. J Vasc Surg. 1986;4(5):473\u0026ndash;478.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIto Y, Funatsu T, Kamata S, Yagihara T. A case of asymptomatic thrombus in the ascending aorta. Jpn J Cardiovasc Surg. 2019;48(1):43\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFayad ZY, Semaan E, Fahoum B, et al. Aortic mural thrombus in the normal or minimally atherosclerotic aorta. Ann Vasc Surg. 2013;27(3):282\u0026ndash;290.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePagni S, Trivedi J, Ganzel BL, et al. Thoracic aortic mobile thrombus: is there a role for early surgical intervention? Ann Thorac Surg. 2011;91(6):1875\u0026ndash;1881.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang B, Ma D, Cao D, Man X. Huge thrombus in the ascending aorta: a case report and literature review. J Cardiothorac Surg. 2019;14(1):157.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaida H, Inoue Y, Kawajiri H, Suzuki S. Rod-shaped giant floating thrombus in a normal ascending aorta. Eur J Cardiothorac Surg. 2015;47(3):582.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713\u0026ndash;719.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGeana RC, Nayyerrani R, Dragulescu RP, et al. COVID-19-related floating thrombus in the ascending aorta: a case report. In Vivo. 2023;37(5):2381\u0026ndash;2386.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSato T, Mishima T, Sato H, et al. A case of thrombus formation in the ascending aorta causing acute myocardial infarction. Jpn J Cardiovasc Surg. 2019;48(3):197\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee KY, Kim SJ, Choi CH, et al. Rod-shaped giant floating thrombus in a nonaneurysmal, nonatherosclerotic ascending aorta. Ann Thorac Surg. 2014;98(6):e139\u0026ndash;e141.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Floating thrombus, ascending aorta, embolic stroke of undetermined source, peripheral arterial embolism, ascending aortic replacement","lastPublishedDoi":"10.21203/rs.3.rs-7134535/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7134535/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: A floating thrombus in the ascending aorta is a rare but potentially life-threatening condition that may present as cerebral or peripheral arterial embolism. Given the limited number of reports, optimal treatment strategies remain unclear.\u003c/p\u003e\n\u003cp\u003eCase presentation: A 49-year-old male presented with acute right lower extremity ischemia during sleep. Emergent thrombectomy of the right common femoral artery was performed, and subsequent imaging revealed a floating thrombus in the ascending aorta. Notably, the patient had suffered a cryptogenic cerebral infarction two months earlier. Elective ascending aortic replacement was undertaken. The thrombus and affected aortic wall segment were excised and replaced with a prosthetic graft. The patient's postoperative course was uneventful.\u003c/p\u003e\n\u003cp\u003eConclusions: This case underscores the importance of considering aortic thrombus in patients with recurrent embolic events of undetermined origin. Surgical resection is advisable not only to prevent recurrence but also to exclude malignancy. Detailed intraoperative decision-making regarding perfusion strategy and aortic clamping should be highlighted, especially in rare cases such as this.\u003c/p\u003e","manuscriptTitle":"Floating Thrombus in the Ascending Aorta Presenting with Recurrent Embolic Events: A Case Report Emphasizing Surgical and Diagnostic Considerations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-25 06:21:10","doi":"10.21203/rs.3.rs-7134535/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-01T18:51:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-01T17:05:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164802770323991209852161658385007454971","date":"2026-03-26T22:29:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T18:49:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339372094022686357661504260429668727926","date":"2025-07-23T18:22:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-22T05:59:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-22T02:09:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-22T02:08:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Heart Journal","date":"2025-07-16T00:47:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b8a8b49f-7a3d-420d-a187-ddc9051c008d","owner":[],"postedDate":"July 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T21:53:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-25 06:21:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7134535","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7134535","identity":"rs-7134535","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}