Idiopathic aortic mural thrombi are a rare cause of embolic disease. There is no consensus in treatment of aortic mural thrombi. Our case is to add to the body of literature regarding the management of this rare condition. Our patient is a 41-year-old Caucasian female with a known aortic mural thrombus presents with an ischemic left lower extremity. Initial diagnosis was made via cross sectional imaging and patient was followed by the diagnosing internist. Patient was lost to follow up and subsequently developed an embolic complication. She was treated with an embolectomy and interval endovascular stent graft placement with successful exclusion of the thrombus. Our case demonstrates that early intervention is important to prevent embolic events. Both medical management and endovascular stent graft placement have been demonstrated as a viable first line of treatments of thoracic aortic thrombi. This patient demonstrated that complications may still arise with patients managed with anticoagulation, especially in patients with a history of poor medical compliance. Thus, patient compliance should be considered in medical decision making and strong consideration be given to early thrombus exclusion.