Abstract
Severe perivisceral aortic thrombus is a rare cause of embolic organ dysfunction with limited treatment guidance. We report a 70-year-old woman with progressive renal failure due to extensive perivisceral and renal artery thrombus. Given high embolic risk, endovascular therapy was deferred, and open aortic endarterectomy was performed. Persistent renal artery compromise necessitated intraoperative conversion to extra-anatomic thoracobirenal bypass. Postoperatively, renal function normalized with durable graft patency at 1 year. A concomitant descending thoracic aortic dissection was managed conservatively. This case highlights the limitations of endovascular therapy in extensive aortic thrombus and supports individualized open revascularization strategies in select patients.