Dear Sirs,
In response to the article by Acharya and Mariscalco on the diagnosis and acute management of type A aortic dissection,1 I would like to expand on the role of pulmonary embolism (PE). The differential diagnosis of type A aortic dissection includes, not only PE, as stated by the authors in table 2 of the article,1 but, also, the co-existence of PE and dissecting aneurysm of the aorta (DAA).2–14
A literature search in Pubmed and Google scholar disclosed 13 examples of the association of type A aortic dissection and PE (table 1).2–14
Table 1. Co-existence of aortic dissection and pulmonary embolism
| First author | Age | Sex | CP | BKP | ARG | PRP | BPD | MDS | SOB | HPTY | DVT | EFF | ARP | Antithrombotic treatment |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cruz2 | 71 | F | ✓ | – | – | ✓ | – | – | ✓ | – | ✓ | – | – | OAC |
| Radwan3 | 66 | F | ✓ | – | – | – | – | – | – | – | – | – | ✓ | Information not available |
| Kagawa4 | 71 | F | – | ✓ | – | – | – | ✓ | – | – | ✓ | ✓ | – | IVC filter, UFH, OAC, elastic stocking |
| Herera5 | 47 | F | – | – | ✓ | – | – | – | ✓ | – | ✓ | – | ✓ | IVC filter, OAC |
| Fernandes6 | 81 | M | ✓ | ✓ | – | – | – | – | – | – | ✓ | – | ✓ | LMWH |
| Ramponi7 | 75 | M | ✓ | ✓ | ✓ | – | – | ✓ | ✓ | – | – | – | ✓ | Pulmonary embolectomy, OAC |
| Bodian8 | 66 | M | ✓ | ✓ | ✓ | – | ✓ | ✓ | ✓ | ✓ | – | – | – | None |
| Morimoto9 | 60 | M | ✓ | ✓ | – | – | – | ✓ | – | – | ✓ | ✓ | – | IVC filter |
| Tudoran10 | 70 | M | ✓ | – | ✓ | – | – | – | ✓ | – | ✓ | – | ✓ | UFH, OAC |
| Volvovitch11 | 73 | F | ✓ | – | – | – | – | – | – | – | – | – | ✓ | Pulmonary embolectomy, OAC |
| Thiam12 | 31 | F | ✓ | – | – | – | – | ✓ | ✓ | ✓ | – | – | – | OAC |
| Leu13 | 59 | F | – | – | – | – | – | – | ✓ | – | – | – | – | Heparin |
| Fukuizumi14 | 81 | F | – | ✓ | – | – | – | ✓ | ✓ | – | – | – | – | Embolectomy, IVC filter, OAC |
| Key: ✓ = presence of that parameter; – = absence of that parameter; ARG = aortic regurgitation; ARP = aortic repair; BKP = back pain; BPD = inter-arm blood pressure difference; CP = chest pain; DVT = deep vein thrombosis; EFF = pleural effusion; F = female; HPTY = haemoptysis; IVC = inferior vena cava; LMWH = low-molecular-weight heparin; M = male; MDS = mediastinal enlargement; OAC = oral anticoagulants; PRP = paraplegia paraparesis; SOB = shortness of breath; UFH = unfractionated heparin | ||||||||||||||
Combination of DAA and PE stigmata suggestive of co-existence of DAA and PE
What seemed to be the most likely combination of DAA stigmata and PE stigmata indicative of the co-existence of DAA and PE was documented in the following patients:
- A patient who had chest pain, back pain, and deep vein thrombosis.6
- A patient who had chest pain, back pain, inter-arm blood pressure difference, breathlessness and haemoptysis, as well as mediastinal enlargement.8
- A patient who had back pain, mediastinal enlargement and deep vein thrombosis.9
- A patient who had chest pain, aortic regurgitation, breathlessness and deep vein thrombosis.10
- A patient who had back pain, mediastinal enlargement, breathlessness, and floating right heart thrombus.14
Caveats and diagnostic traps
In Bhat et al., a 21-year-old man presented with severe chest pain and mild dyspnoea. Computed tomographic angiography (CTA) showed, not only stigmata of DAA, but, also, apparent filling defects in the right and left pulmonary arteries. However, during operative repair of the aorta, the pulmonary arteries were also opened and explored, and were found to be completely free of thrombus. In this instance, the angiographic signs suggestive of PE were, in fact, attributable to DAA-related compression of the pulmonary artery.15
Conversely, in Neri et al., DAA-related compression of the pulmonary artery did result in thrombotic occlusion of the pulmonary artery. Subsequent operative intervention involved operative aortic repair as well as pulmonary artery thrombectomy.16
Treatment strategies for DAA
Seven patients were managed without aortic repair,2,4,8,9,12–14 three of whom subsequently died.8,12,13 Among the four survivors of conservative DAA management was an 81-year-old patient in whom co-existing thromboembolism was managed by surgical embolectomy involving extraction of a floating right heart thrombus located in the right atrium, and subsequent oral anticoagulation using warfarin.14 Also managed without aortic repair was a 71-year-old woman in whom PE was managed by insertion of an inferior vena cava filter followed by oral anticoagulation.4
Six patients were managed by aortic repair,3,5–7,10,11 two of whom died.6,10 Among the survivors were two patients who were managed by the combined operative strategy of aortic repair (for DAA) and pulmonary embolectomy (for PE).7,11
Treatment strategies for PE
The range of treatment strategies included intravenous unfractionated heparin, vitamin K antagonists, insertion of inferior vena cava filter, and pulmonary embolectomy. There was one patient who did not receive any of those treatment strategies. That patient died soon after the dual diagnosis of DAA and PE was made.8 In one other instance, information about prescription, or absence of prescription, of antithrombotic measures was not available.3
Take home message
Clinicians should be vigilant for the co-existence of DAA and PE so that measures can be taken to mitigate the risk of a potential PE-related fatal outcome.
Conflicts of interest
None declared.
Funding
None.
Acknowledgement
I am indebted to Peter Laws for compiling table 1.
References
1. Acharya M, Mariscalco G. Diagnosis and acute management of type A aortic dissection. Br J Cardiol 2023;30:62–8. https://doi.org/10.5837/bjc.2023.012
2. Cruz I, Caldeira D, Stuart B et al. A case of pulmonary thromboembolism and aortic dissection: the role of echocardiography. Rev Port Cardiol 2013;32:549–50. https://doi.org/10.1016/j.repc.2012.12.010
3. Radwan K, Peszek-Przbyla E, Gruszka A, Sonsowski M, Buszman P. Acute aortic dissection imitating ST elevation myocardial infarction with accompanying pulmonary embolism. Cardiol J 2007;14:595–6. Available from: https://journals.viamedica.pl/cardiology_journal/article/view/21658
4. Kagawa Y, Ota S, Hoshino K et al. Acute pulmonary thromboembolism and deep vein thrombosis during the medical treatment of acute aortic dissection was successfully treated by the combination of inferior vena cava installation and anticoagulant therapy: a case report. Ann Vasc Dis 2015;8:36–9. https://doi.org/10.3400/avd.cr.14-00083
5. Herrera RN, Miott JA, Perreyra AS et al. Marfan syndrome associated with aortic dissection, venous thromboembolism and hyperhomocysteinemia [article in Spanish]. Medicina (B Aires) 2012;72:478–80. Available from: https://www.medicinabuenosaires.com/PMID/23241291.pdf
6. Fernandes S, Rodrigues M, Barreiros C et al. An incident of a massive pulmonary embolism following acute aortic dissection. J Crit Care Med 2021;7:67–72. https://doi.org/10.2478/jccm-2021-0001
7. Ramponi F, Papps T, Edwards J. Successful repair of concomitant acute type A aortic dissection and saddle pulmonary embolism. Aorta (Stamford) 2018;6:34–6. https://doi.org/10.1055/s-0038-1639345
8. Bodian M, Guindo AS, Aw F et al. Double emergency associating acute aortic dissection and pulmonary embolism of fatal evolution: about a case. J Clin Exp Cardiol 2018;9:12. https://doi.org/10.4172/2155-9880.1000617
9. Moromoto S, Izumi T, Sakurai T et al. Pulmonary embolism and deep vein thrombosis complicating acute aortic dissection during medical treatment. Intern Med 2007;46:477–80. https://doi.org/10.2169/internalmedicine.46.6215
10. Tudoran M, Tudoran C. High-risk pulmonary embolism in a patient with acute dissecting aortic aneurysm. Niger J Clin Pract 2016;19:831–3. https://doi.org/10.4103/1119-3077.181355
11. Volvovitch D, Ram E, Cohen H et al. Acute pulmonary embolism following acute type A dissection in a patient with COVID-19. J Card Surg 2012;36:1566–8. https://doi.org/10.1111/jocs.15389
12. Thiam C, Sonfo B, Camara Y et al. Double emergency pulmonary embolism and aortic dissection: about a clinical case. World J Cardiovasc Dis 2020;10:550–7. https://doi.org/10.4236/wjcd.2020.108054
13. Leu H-N, Yu W-C. Massive pulmonary embolism in a patient with type A dissection. Clin Cardiol 2005;28:53. https://doi.org/10.1002/clc.4960280113
14. Fikuizumi A, Akutsu K, Tokita Y et al. Surgical thrombectomy for right heart thrombus with acute aortic dissection. Ann Thorac Cardiocasc Surg 2014;20(suppl):937–40. https://doi.org/10.5761/atcs.cr.13-00218
15. Bhatt K, Navia J, Flamm S, Bolen M. Type A aortic dissection mimicking a saddle pulmonary embolus on computed tomography angiography. Circulation 2014;129:2180–2. https://doi.org/10.1161/CIRCULATIONAHA.114.008819
16. Neri E, Toscano T, Civeli L et al. Acute dissecting aneurysm of the ascending thoracic aorta. Tex Heart Inst J 2001;28:149–50. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC101158/
