Primary Aortic Mural Thrombus: Clinical Presentation, Embolization Patterns, and Early Outcomes in a Consecutive Series.

OBJECTIVE: Primary aortic mural thrombus (PAMT) is an uncommon but clinically important source of systemic arterial embolization. This study aimed to describe the clinical presentation, anatomical distribution, treatment strategies, and early outcomes of patients with PAMT. METHODS: Consecutive patients diagnosed with PAMT at a tertiary vascular center between January 2018 and December 2024 were retrospectively reviewed. PAMT was defined as an aortic mural thrombus diagnosed primarily on arterial-phase computed tomography angiography in the absence of aortic aneurysm, dissection, or significant atherosclerotic disease. Clinical presentation, anatomic thrombus location, distal embolization territories, treatment strategy, follow-up imaging findings, recurrent embolization, repeat vascular intervention, and 90-day mortality were analyzed descriptively. RESULTS: Twenty-three patients were included. The median age was 56 years, and 20 patients were male. Acute lower limb ischemia was the most common presentation, occurring in 17 patients. Infrarenal abdominal aortic thrombus was the most frequent anatomic location, and the iliac arterial system was the most commonly involved embolization territory. Iliac and lower-extremity embolization predominated among patients with infrarenal abdominal aortic thrombus, whereas visceral embolization was mainly observed in patients with suprarenal abdominal or multisegmental aortic thrombi. Endovascular aortic treatment was performed in 15 patients, open surgical aortic treatment in three, and medical management of the aortic thrombus without direct aortic intervention in five. The median follow-up duration was 3 months. During early follow-up, thrombus regression or resolution was observed in 18 patients, whereas persistent thrombus occurred in five. Recurrent embolization and repeat vascular intervention occurred in three patients each. The 90-day mortality rate was 8.7%. CONCLUSIONS: In this small retrospective consecutive series, PAMT most commonly presented with acute lower limb ischemia and was frequently located in the infrarenal abdominal aorta. Descriptive imaging analysis suggested that embolization territories may vary across anatomic thrombus locations, but this observation should be considered hypothesis-generating. Persistent thrombus and recurrent embolization occurred in a minority of patients during early follow-up. Standardized imaging assessment, etiologic evaluation, treatment reporting, and longer follow-up are needed to refine the management of PAMT.