2019 Research Forum

Robin Boyer MS IV, Carlos D’Assumpcao MD R1, Fowrooz Joolhar MD, Aslan Ghandforoush DO, Tiffany Win MD Ross University School of Medicine | Department of Medicine, Cardiology, Kern Medical An Extensive Complex Type A Acute Aortic Dissection with Thrombus in Aortic Arch: A Therapeutic Dilemma

Introduction

Outcome

Repeat neuroimaging revealed multiple small infarcts suggestive of an embolic event.

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Urgent intervention is recommended in Stanford Type A acute aortic dissection (AAD). Non-operative management of Stanford type A AAD is associated with significantly high mortality. Though rare, arterial thrombus is likely with endothelial exposure. We report a case of an extensive complex Stanford type A AAD with thrombus formation within the aortic arch leading to thromboembolic stroke ultimately medically managed with full dose anticoagulation. A 52-year-old obese 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 subsequently became hypotensive and was intubated with vasopressors support in the emergency room. 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 45-50%. Urine toxicology revealed methamphetamine metabolites. Patient could not be extubated over several spontaneous breathing trials due to agitation and inability to follow commands during sedation holidays. surgical Case Presentation

She was deemed non-operative by two tertiary care centers. Medical management included blood pressure control and full dose unfractionated heparin anticoagulation therapy with stable hospital course. She is able to participate with physical therapy and was successfully transitioned to warfarin. Patient was successfully discharged on hospital day 39. Family drove her home to Missouri and she established care with a primary care physician. Conclusions Although urgent surgical intervention is indicated in Type A AAD, the therapeutic strategy and extent of anticoagulation in a patient complicated with multiple thromboembolic strokes is currently unknown. Sinha Y, Saleh M, Weinberg D. Use of heparin in aortic dissection: beware the misdiagnosis of acute pulmonary embolism. BMJ Case Reports. 2013;2013:bcr2013009367. doi:10.1136/bcr-2013-009367. Zurick AO, Ramaiah C. Aortic Mural Thrombus in Association with Occult Aortic Dissection. CASE : Cardiovascular Imaging Case Reports. 2017;1(2):62-64. doi:10.1016/j.case.2017.01.001. Liu Y, Han L, Li J, Gong M, Zhang H, Guan X. Consumption coagulopathy in acute aortic dissection: principles of management. Journal of Cardiothoracic Surgery. 2017;12:50. doi:10.1186/s13019-017-0613-5. Zafar MA, Pang PYK, Henry GA, Ziganshin BA, Tranquilli M, Elefteriades JA. Early Spontaneous Resolution of an Iatrogenic Acute Type A Aortic Dissection. AORTA Journal. 2016;4(6):235-239. doi:10.12945/j.aorta.2016.16.067. Weigang E, Nienaber CA, Rehders TC, Ince H, Vahl C-F, Beyersdorf F. Management of Patients With Aortic Dissection. Deutsches Ärzteblatt International. 2008;105(38):639-645. doi:10.3238/arztebl.2008.0639. References

Image A: Initial CT head without acute process. Image B: Hospital day 6 CT head showed bilateral cerebellar infarcts and lacunar infarct in pons. Images C and D: MRI brain diffusion coefficient b1000 revealed bilateral multiple chronic an acute infarcts in frontal, parietal and occipital lobes and cerebellum. Transesophageal echocardiogram demonstrated a large aortic arch thrombus along with dissection of the aortic root, ascending aorta, aortic arch and descending aorta with false and true lumen throughout.

CT angiogram confirmed AAD involving the right brachiocephalic artery with extension into bilateral common carotids and subclavian arteries that further extend inferiorly along the thoracic and abdominal aorta involving bilateral common, internal and external iliac arteries. The celiac trunk, hepatic artery and proximal superior mesenteric artery are also affected. A prominent clot within the right inferior lobar artery extending to the sub segmental branches was also found.

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