Massive aortic thrombus in a hypercoagulable patient with heparin induced thrombocytopenia: a case report

Large ascending aortic thrombus can lead to devastating consequences and requires astute recognition and evaluation, systemic anticoagulation, and urgent surgical intervention. Perioperative and surgical management of a large ascending aortic thrombus is further complicated in patients who develop heparin induced thrombocytopenia (HIT) as the risks of further thrombosis and perioperative bleeding must be carefully navigated. We report the case of a patient who presents with multiple thromboses, including a massive ascending aortic mural thrombus, indicative of an underlying hypercoagulable state, who developed acute HIT after systemic anticoagulation and required urgent cardiac surgery for removal of the aortic thrombus. Following stabilization of acute HIT with argatroban, surgical thrombectomy of the large aortic thrombus and endarterectomy of a penetrating aortic ulcer was successfully performed using bivalirudin anticoagulation for cardiopulmonary bypass without complication. Postoperatively the patient was maintained on argatroban followed by transition to outpatient warfarin without new thromboembolic or bleeding complications.