Chronic pulmonary thromboembolism and chronic aortic dissection: A surgery challenge

doi:10.21203/rs.3.rs-2814288/v1

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Case Report

Chronic pulmonary thromboembolism and chronic aortic dissection: A surgery challenge

https://doi.org/10.21203/rs.3.rs-2814288/v1

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Acute aortic dissection and acute pulmonary embolism are both life-threatening emergencies. The presented case is of a 70-year-old patient with chronic aortic dissection, an incidental finding in the pulmonary tomography during the study of chronic pulmonary thromboembolism. Initially, it was considered to carry out the two simultaneous procedures but considering her age and the fact that she had a chronic aortic dissection without root dilation, it was concluded that she had more risk than benefit from carrying out the aortic replacement procedure. For this reason, it was decided to perform only a pulmonary thromboendarterectomy, resulting in a short hospital stay with subsequent outpatient control and symptomatic improvement. This was achieved with good pre-surgical planning and without carrying out a mixed procedure with high morbidity and mortality.

Chronic aortic dissection

pulmonary hypertension

thromboendarterectomy

Pulmonary endarterectomy is the treatment of choice for pulmonary hypertension secondary to chronic thromboembolic disease (group IV pulmonary hypertension). This pathology occurs in between 0.8 and 3.8% of patients with acute pulmonary embolisms and in more than 10% of those with recurrent embolisms. In this case report, a patient with chronic pulmonary thromboembolism and a type A aortic dissection are presented, which is why it is considered a case of interest regarding treatment decisions.

We present the case of a 70-year-old female patient with a known medical history of chronic pulmonary thromboembolism and venous insufficiency; she had been receiving rivaroxaban 20 mg daily, irregularly.

She was admitted to our hospital with dyspnea at rest, chest pain, and edema of the lower limbs for one week. A pulmonary CT angiography reported acute central pulmonary thromboembolism in the left lobe branch. Ventilation/perfusion SPECT lung scintigraphy (V/Q-SPECT) reported multiple segmental involvements in both lungs, severe in the right lung.

Right catheterization was performed with pulmonary arteriography that reported healthy coronary arteries and severe pulmonary hypertension, categorized as group IV.

Considering the discrepancy between the initial pulmonary CT angiography and the PET V/Q scintigraphy finding, it was decided to complement studies with a new pulmonary CT angiogram and transthoracic echocardiogram to assess thrombus accessibility for a possible pulmonary thromboendarterectomy. A new study confirms chronic and subacute pulmonary thromboembolism with main involvement of the right lower lobe, bilateral lower lobe pulmonary infarcts, signs of overload of the right cavities, and pulmonary hypertension.

Additionally, there was an unexpected finding of thoracic aortic dissection with an intimal dissection flap in the distal aortic arch with extension to the descending thoracic aorta and supra-aortic trunks originating from the true lumen (Fig. 1).

The management of surgical thrombendarteriectomy and repair of aortic dissection is considered, so it is transferred to surgery rooms. Intraoperatively, a TE echocardiogram was performed, where a false lumen thrombosis was observed, together with an intramural hematoma, but without an aneurysm of the aortic root. Given the findings described, a chronic dissection was considered, and it was decided not to perform any intervention on the aortic root; therefore, only surgical thrombendarteriectomy is performed under extracorporeal circulation and hypothermia at 18 degrees Celsius, requiring two periods of circulatory arrest, one of 20 minutes and the other of 10 minutes, a procedure that was completed without complications. (Figure.2)

She was transferred to the intensive care unit, where she stayed for 4 days. Medical management was adjusted without the need for parenteral prostanoid, and after 8 days of postoperative surveillance, the patient was discharged with anticoagulation. In outpatient follow-up, a patient with symptomatic improvement is found.

The acute aortic dissection and its correction have a mortality of approximately 20%, and pulmonary thromboendarterectomy surgery, in turn, is a complex procedure that requires circulatory arrest with profound hypothermia, so the combination of both surgeries in a short period of time makes it a prohibitive risk for the patient (1–4).

In the literature, there is diverse information in this regard. Ishida et al. report a case of surgery in two stages in the context of an acute dissection, in which hemiarch replacement was performed with hypothermia and circulatory arrest with ECMO-V-A (extracorporeal membrane oxygenation) for 5 days and subsequent pulmonary thromboendarterectomy intervention on day 8, which was successful (5). On the other hand, Thistlethwaite et al show in their retrospective study that performing procedures concomitant with thromboendarterectomy in the rewarming period is safe for procedures such as foramen ovale closure, mitral and aortic valve replacement, tricuspid valve surgery, and myocardial revascularization (6.7).

It is known that acute aortic dissection is a pathology with a mortality rate of 23%, even with surgical management, with the worst prognostic markers being a prior shock, aortic rupture, neurological damage, visceral ischemia, and age over 70 years (6.8). On the other hand, the natural history of chronic aortic dissection has not been fully resolved, and many questions remain. It has been commonly defined that the condition is chronic when it occurs after 14 days from the onset of symptoms, although the cut-off point is now set at 90 days. Patients who present with chronic type A aortic dissection are usually asymptomatic and are diagnosed incidentally by imaging findings (9).

Kim et al. evaluated the evolution of 82 patients with type A chronic aortic dissection; the study concludes that the baseline aortic diameter and age emerged as significant and independent factors associated with aortic events, considering that the surgical limit could be 55 mm. Given the above, they recommend offering surgery to patients with an aortic diameter close to the surgical limit, as long as the patient's basic conditions allow it and the benefit of surgery is greater than the risks of the disease (10). In our case, the chronic dissection did not present with surgical aortic dilation or poor prognostic factors, so conservative management was considered, and only surgical management of his type IV pulmonary hypertension with bilateral thrombendarteriectomy was considered.

The association between aortic dissection and pulmonary embolism is a morbid combination, and management remains a challenge in everyday clinical practice. We consider that each patient should be individualized, taking as a guide the predictive factors of poor clinical outcomes, to achieve the best possible result.

Ethical Approval

The institutional review board approved the study protocol, and the patient signed the informed consent for publication.

Competing interests

The authors declare that they have no financial or non-financial competing interests.

Authors' contributions

All authors contributed equally to this work.

Availability of data and materials

Data that support the findings of this study are available from the corresponding author.

Becattini C, Agnelli G, Pesavento R, et al. Incidence of chronic thromboembolic pulmonary hypertension after the first episode of pulmonary embolism. Chest 2006; 130: 172–175.
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Thistlethwaite, P. A., Auger, W. R., Madani, M. M., Pradhan, S., Kapelanski, D. P., & Jamieson, S. W. (2001). Pulmonary thromboendarterectomy combined with other cardiac operations: indications, surgical approach, and outcome. The Annals of thoracic surgery, 72(1), 13-18.
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Authors/Task Force members, Erbel, R., Aboyans, V., Boileau, C., Bossone, E., Bartolomeo, R. D., ... & Kravchenko, I. (2014). 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 (ESC). European heart journal, 35(41), 2873-2926.
Kim, W. K., Park, S. J., Kim, H. J., Kim, H. J., Choo, S. J., & Kim, J. B. (2019). The fate of unrepaired chronic type A aortic dissection. The Journal of Thoracic and cardiovascular surgery, 158(4), 996-1004

No competing interests reported.

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Chronic pulmonary thromboembolism and chronic aortic dissection: A surgery challenge

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