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.