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 state4.
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
wall5. The pathophysiology of these lesions is
unclear, since thrombophilic states are not frequently
found2, as in this case. Medical management with
heparinization, endovascular stenting and surgery have been proposed and
previously published, but comparative data are not
available.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.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.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.