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Right pulmonary artery occlusion by an acute dissecting aneurysm of the ascending aorta
© De Silva et al; licensee BioMed Central Ltd. 2006
Received: 22 June 2006
Accepted: 28 September 2006
Published: 28 September 2006
We describe the case of a 76-year old female who presented with a Type A aortic dissection requiring repair with an interposition graft and aortic valve replacement. Post-operatively she had clinical features and computerised tomographic images suggestive of a pulmonary embolus and died 24 hours later. The extremely rare finding of intramural thrombus occluding the right pulmonary artery was seen at post mortem.
Acute type A aortic dissection is a serious and life-threatening condition that requires prompt diagnosis and surgical treatment. The presenting symptom of chest pain is often erroneously attributed to either myocardial infarction or pulmonary embolus. We describe an exceptionally rare presentation of acute type A aortic dissection combined with occlusion of the right pulmonary artery.
Acute aortic dissections and pulmonary emboli are often diagnosed post-mortem . Both conditions present with similar symptoms, and can be rapidly fatal. Occlusion of the pulmonary artery by an acute aortic dissection is an extremely rare finding [1–8]. It was first described by Buja and colleagues , since when only a few cases have been reported in the literature. The right PA is susceptible to extrinsic compression by the haematoma of an aortic dissection due to its anatomical relationship to the aorta and as it shares a common tunica adventitia, thereby enabling a haematoma to track back from the aorta and up the PA. The previously reported cases are in patients who were initially thought to have had only a PE, or many years following aortic valve replacement. In only three instances have the patients survived. In these cases the thrombus was either evacuated [3, 4] or the pulmonary trunk replaced with a prosthesis .
We present a case of acute aortic dissection, which initially underwent successful surgical correction. Despite attempts to surgically enlarge the main PA, the patient developed signs consistent with an acute PE several hours post-operatively. Subsequent investigation revealed further compression of the main and right PA, possible as a result of anticoagulation during cardiopulmonary bypass. The poor clinical condition of the patient at this point made further aggressive management futile. Post mortem findings revealed an extremely rare scenario that would not have been amenable to surgical embolectomy or thrombolysis. The rarity of this clinical presentation may be due to the poor antemortem diagnosis of both aortic dissection and pulmonary embolus. We suggests that patients who present with a massive unilateral perfusion defect, or hypoxic patients with an acute aortic dissection should be investigated with both CT and pulmonary arteriography, so that this unusual presentation is not overlooked and the chance of a surgical cure missed.
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