2019 Research Forum

Applicant: Robin Boyer MS IV Principal Investigator: Tiffany Win MD Faculty Sponsor: Fowrooz Joolhar MD

An Extensive Complex Type A Acute Aortic Dissection with Thrombus in Aortic Arch: A Therapeutic Dilemma

Robin Boyer MS IV, Carlos D’Assumpcao MD R1, Aslan Ghandforoush MD, Fowrooz Joolhar MD, Tiffany Win MD

INTRODUCTION Urgent surgical intervention is recommended in Stanford Type A acute aortic dissection. Non-operative management of Stanford type A acute aortic dissection is associated with significantly high mortality. Though rare, arterial thrombus is likely with endothelial exposure. We report a case of complex Stanford type A acute aortic dissection with thrombus formation within the aortic arch leading to multiple thromboembolic strokes medically managed with full dose anticoagulation. PURPOSE The purpose of this report is to help enable cardiovascular clinicians to consider therapeutic guidelines of anticoagulation in patients with inoperable acute aortic dissection where there is high risk of arterial thrombus formation.This study was approved by the Kern Medical Research Program and Institutional Review Board and performed in accordance with its policies. DISCUSSION A 52-year-old female with hypothyroidism presented to the emergency department after a syncopal episode. Initial vitals showed pulse 78 bpm and blood pressure 170/101 mmHg. She became hypotensive and was intubated with vasopressor support. Clinical examination was significant for discrepancy in extremity blood pressures. Initial neuroimaging was negative for acute process. Transthoracic echocardiogram revealed grade 1 left ventricular diastolic dysfunction and an estimated left ventricular ejection fraction of 50%. Due to persistent deterioration in neurological status, follow-up neuroimaging revealed multiple small infarcts suggestive of an embolic event. Trans-esophageal echocardiogram demonstrated a large aortic arch thrombus along with dissection of the whole aorta; including the aortic root with false and true lumen throughout. CT angiogram confirmed acute aortic dissection involving the right brachiocephalic artery with extension into bilateral common carotids and subclavian arteries that further extend inferiorly to bilateral common, internal and external iliac arteries. The celiac trunk, hepatic artery and proximal superior mesenteric artery were also affected. Additionally, a prominent clot within the right inferior lobar artery extending to the subsegmental branches was found. The patient was deemed a non-operative candidate. Medical management included blood pressure control and full dose unfractionated heparin anticoagulation therapy with stable hospital course. CONCLUSION Although urgent surgical intervention is indicated in Stanford Type A acute aortic dissection, therapeutic strategy and extent of anticoagulation in a patient complicated with multiple thromboembolic events is currently unknown. Our patient is currently doing well on conservative management.

66