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.