\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Operative management of ascending aorta thrombus and bilateral pulmonary
embolism in the setting of breast cancer}



\author[1]{Jorge Alcocer}%
\author[2]{María Ascaso}%
\author[2]{Eduard Quintana}%
\author[3]{Elena Sandoval}%
\author[1]{Manuel Castella}%
\affil[1]{Department of Cardiovascular Surgery, Institut Clinic Cardiovascular, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain}%
\affil[2]{Hospital Clínic}%
\affil[3]{Hospital Clínic, Cardiovascular Surgery}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Pulmonary embolism and concomitant floating aortic thrombus are a rare
and potentially life-threatening association. Several therapeutic
options are available and best management can be controversial when
these conditions coexist. We describe a case of a 79-year-old woman
presented with massive pulmonary embolism and simultaneous floating
thrombus in the ascending aorta. She underwent concomitant ascending
aortic replacement and surgical pulmonary embolectomy with an uneventful
postoperative recovery. Open surgical repair is a one stage repair
approach that may offer the most efficient treatment to allow survival.%
\end{abstract}%



\sloppy


\textbf{Operative management of ascending aorta thrombus and bilateral
pulmonary embolism in the setting of breast cancer}

\textbf{Aortic thrombus and pulmonary embolism}

Jorge Alcocer MEBCTS*, Mar\selectlanguage{ngerman}ía Ascaso MD, Eduard Quintana PhD, Elena
Sandoval FEBCTS, Manuel Castellá PhD

Cardiovascular Surgery Department, Hospital Clinic, Barcelona, Spain

*Corresponding author:

Dr. Jorge Alcocer

Department of Cardiovascular Surgery, Hospital Clinic Barcelona

C/ Villarroel 170, 08036, Barcelona, Spain

Phone: + 34 932 275400 (Ext: 387006)

E-mail: \emph{alcocer@clinic.cat}

Funding: There has not been any source of funding for this work.

Disclosures: The authors have no relationships relevant to the contents
of this paper to disclose.

Institutional Review Board approval: N/A

Clinical trial registration: N/A

Consent statement: Oral consent was obtained and the patient voluntarily
authorized us to write a case report about her treatment and to share
medical information related to it (diagnostic images, photos and videos)

Data availability statement: Data sharing is not applicable to this
article as no datasets were generated during the current study.

\textbf{Abstract}

Pulmonary embolism and concomitant floating aortic thrombus are a rare
and potentially life-threatening association. Several therapeutic
options are available and best management can be controversial when
these conditions coexist.

We describe a case of a 79-year-old woman presented with massive
pulmonary embolism and simultaneous floating thrombus in the ascending
aorta. She underwent concomitant ascending aortic replacement and
surgical pulmonary embolectomy with an uneventful postoperative
recovery.

Open surgical repair is a one stage approach that may offer the most
efficient treatment to allow survival.

\textbf{Key words}

Pulmonary embolism, aortic thrombus, breast cancer, pulmonary
embolectomy, aortic replacement, hypercoagulability

\textbf{Introduction}

Pulmonary embolism (PE) is a medical condition usually managed with
anticoagulation or thrombolysis, however in certain cases surgical
management can be considered as the best therapeutic
intervention\textsuperscript{1}. Floating aortic thrombus can lead to
catastrophic systemic embolism and operative management prevents this
complication\textsuperscript{2,3}. Several reports of successful
systemic anticoagulation alone have been reported. Concomitant
presentation of both conditions poses extra challenge to clinical
decision making to ensure the best possible outcome.

\textbf{Case}

A 79-year-ol woman presented at emergency department complaining of
progressive dyspnea, cough with mild hemoptysis and pleuritic chest pain
for one week. The patient´s medical history was remarkable for the
presence of systemic arterial hypertension and recent surgery for stage
I breast cancer three months ago. After surgery, the patient started
adjuvant therapy with aromatase inhibitor letrozole and local
radiotherapy until the time of admission. She disclosed neither smoking
habit nor alcohol consumption. Systemic temperature was 37 ºC, her
oxygen saturation was 95\% with room air and systemic blood pressure was
120/60 mmHg. Physical examination revealed mild tachypnea and a heart
rate of 110 beats per minute. Cardiac and pulmonary auscultation did not
show any other abnormality. Peripheral pulses were palpable in all
extremities and no swelling was present in lower limbs.

Twelve-lead surface electrocardiogram and chest-x-ray did not show any
pathological finding. Laboratory testing revealed a normal blood cell
count, renal and liver function and lipid profile. Cardiac markers were
slightly elevated (high-sensivity troponin I 106 ng/L, normal range
\textless{} 45 ng/L) and D-dimer was 1200 ng/ml (normal range
\textless{} 250 ng/ml). Basic clotting test showed normal platelet
count, international normalized ratio, activated partial thromboplastin
time and fibrinogen levels. Transthoracic echocardiography showed normal
left ventricular function and dilated right ventricle with preserved
contractility. There were no valvular abnormalities, shunts or
pericardial effusion and visualized ascending aorta was normal. Finally,
computed tomography (CT) pulmonary angiogram showed a saddle PE
extending into the lobar arteries of both lungs (Figure 1A).
Furthermore, there was an intraluminal filling defect in distal
ascending aorta corresponding to a floating thrombus (Figure 1B).

The patient was admitted at the ICU due to progressive hypoxemia and
intravenous heparin was initiated. Diagnosis of simultaneous high-risk
PE and a floating thrombus in the ascending aorta, as a potential source
of stroke or peripheral emboli, mandated an open surgical repair. In
order to rule out metastatic disease, a total body CT scan and bone
scintigraphy were performed and did not reveal any lesion suggestive of
cancer metastasis.

After median sternotomy, right axillary artery and bicaval cannulation,
cardiopulmonary bypass was instituted and cardioplegic arrest was
obtained by means of retrograde cold blood cardioplegia. The patient
underwent thrombus resection and ascending aortic replacement with a 28
mm dacron graft. Due to distal location of thrombus and calcification of
the distal portion of the ascending aorta, an open distal anastomosis
was performed with systemic circulatory arrest, moderate hypothermia
(25ºC) and bilateral selective cerebral perfusion. After systemic and
coronary reperfusion, we carried out a surgical pulmonary
thromboembolectomy through a separate longitudinal arteriotomy in left
and right pulmonary arteries (Supplementary video)

Aortic thrombus was 2 cm in size, pale and pedunculated over a calcified
atheromatous plaque in the anterior wall of the distal ascending aorta
(Figure 2). Moreover, a great amount of soft and dark red thrombus was
taken out from both pulmonary arteries extending into lobar and
segmental arteries (Figure 3).

The postoperative course was uneventful and a thorough coagulation
testing was performed postoperatively to rule out a hypercoagulable
state. Therefore, anticardiolipine antibodies, lupus anticoagulant,
B2-glycoprotein, protein C activity, antithrombin activity and
homocysteine levels were strictly normal. Postoperative CT angiogram
revealed a normal appearance of ascending aortic graft and good
perfusion of both pulmonary arteries with no residual pulmonary emboli
(Figure 4).

Finally, the patient was discharged at postoperative day 10, aromatase
inhibitor letrozole was discontinued and direct oral anticoagulant
edoxaban was initiated. At 6 months, the patient is completely recovered
with good functional class.

\textbf{Discussion}

In this case, we found a very unusual association of two thrombotic
conditions with different pathogenic mechanisms and potential
life-threatening complications. Recent history of cancer and current
treatment with letrozole were considered the only factors associated
with this prothrombotic state\textsuperscript{4}.

On the one hand, floating aortic thrombus is an unusual disease,
frequently detected in the setting of diagnostic work-up after stroke or
peripheral embolism. Thrombi are mostly located in the aortic arch and
can be attached either on aortic plaques or visually normal
wall\textsuperscript{5}. The pathophysiology of these lesions is
unclear, since thrombophilic states are not frequently
found\textsuperscript{2}, as in this case. Medical management with
heparinization, endovascular stenting and surgery have been proposed and
previously published, but comparative data are not
available.\textsuperscript{5,6}

On the other hand, usual treatment of PE consists in systemic
anticoagulation. Systemic fibrinolysis is indicated in case of
hemodynamic or cardiac compromise and surgical embolectomy is reserved
for those cases where fibrinolysis is contraindicated or
failed.\textsuperscript{7} This case was a high-risk PE without
hemodynamic instability and could only be managed with anticoagulation
alone and systemic fibrinolysis in case of hemodynamic
deterioration.\textsuperscript{1} However, the presence of floating
thrombus in the ascending aorta with a high risk of stroke led to
concomitant surgical repair of both conditions. Some circumstances other
than contraindication for fibrinolysis can make surgical pulmonary
embolectomy the best approach PE management.

\textbf{Authors Contribution}

Jorge Alcocer provided concept and design.

María Ascaso drafted the manuscript

Eduard Quintana, Elena Sandoval and Manuel Castellá provided critical
revision and approved the submitted version

\textbf{References}

1. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines
for the diagnosis and management of acute pulmonary embolism developed
in collaboration with the European Respiratory Society (ERS).~\emph{Eur
Respir J} . 2019;54(3):1901647

2. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the
diagnosis and treatment of aortic diseases: Document covering acute and
chronic aortic diseases of the thoracic and abdominal aorta of the
adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases
of the European Society of Cardiology.~\emph{Eur Heart J} .
2014;35(41):2873\selectlanguage{english}-2926.

3. Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromboses of the
aortic arch without aortic debris. A transesophageal echocardiographic
finding associated with unexplained arterial embolism. The Filiale
Echocardiographie de la Societe Francaise de
Cardiologie.~\emph{Circulation} . 1997;96(1):288\selectlanguage{english}-294.

4. Bundred NJ. The effects of aromatase inhibitors on lipids and
thrombosis.~\emph{Br J Cancer} . 2005;93 Suppl 1:S23\selectlanguage{english}-S27.

5. Toyama M, Nakayama M, Hasegawa M, Yuasa T, Sato B, Ohno O. Direct
oral anticoagulant therapy as an alternative to surgery for the
treatment of a patient with a floating thrombus in the ascending aorta
and pulmonary embolism.~\emph{J Vasc Surg Cases Innov Tech} .
2018;4(2):170\selectlanguage{english}-172.

6. Goette A, Hammwohner M, Dierkes J, et al. Aortic thrombus and
pulmonary embolism in a patient with hyperhomocysteinemia.~\emph{Nat
Clin Pract Cardiovasc Med} . 2006;3(7):396\selectlanguage{english}-399.

7. Carvalho EM, Macedo FIB, Panos AL, et al. Pulmonary embolectomy:
recommendation for early surgical intervention. J Card Surg.
2010;25(3):261\selectlanguage{english}-266.

Figure 1

A. Preoperative CT pulmonary angiogram shows a saddle pulmonary embolism
(Red asterisk)

B. Chest CT reveals a floating thrombus in the anterior wall of distal
ascending aorta (black asterisk) and pulmonary embolism extending into
lobar arteries (red asterisk)

Figure 2

Intraoperative view of thrombus attached to an atheromatous plaque in
the ascending aortic wall

Figure 3

Surgical pulmonary embolectomy specimen from right (A) and left side (B)

Figure 4

A. Postoperative CT angiogram showing normal appearance of ascending
aortic graft

B. Postoperative pulmonary angio-CT showing no residual pulmonary emboli
and normal perfusion of main pulmonary arteries and lobar branches

\textbf{Hosted file}

\verb`Imagenes case report.pptx`  available at \url{https://authorea.com/users/378402/articles/494919-operative-management-of-ascending-aorta-thrombus-and-bilateral-pulmonary-embolism-in-the-setting-of-breast-cancer}

\selectlanguage{english}
\FloatBarrier
\end{document}

