Ascending aorta thrombus adjacent to a cholesterol-rich plaque as the source of multiple emboli

Ascending aortic thrombus causing thromboembolism in the absence of hyper-coagulable states is a rare occurrence. We present a case of a 40-year old healthy female smoker who presented with a 6-month history of three transient ischaemic attacks, hand pain and numbness despite being on dual anti-platelet therapy. Computed tomography revealed a mid-ascending aorta thrombus. She underwent ascending aorta replacement on cardiopulmonary bypass, but without the use of circulatory arrest. She recovered uneventfully. We identified a fresh thrombus adjacent to a soft, cholesterol-rich plaque as the culprit lesion. We advocate surgical excision of such lesions as the only way of removing the underlying cause of thromboembolism. In addition, rupture-prone aortic plaques may lead to a penetrating aortic ulcer or an intramural haematoma and ultimately aortic dissection.