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
< 45 ng/L) and D-dimer was 1200 ng/ml (normal range
< 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.