VCOM Louisiana Research Day Program

Clinical & Case Studies

Ahmad Fouad Chaban 1 , OMS-III; Eric Thomas 2 , MD; Zakaria Y. Abd Elmageed 1 , PhD Edward Via College of Osteopathic Medicine-Louisiana, Monroe, Louisiana; Willis-Knighton Medical Center, Shreveport, Louisiana 12 CARDIAC EMERGENCY: ACUTE SADDLE PULMONARY EMBOLISM, INTRAMURAL HEMATOMA, AND AORTIC ANEURYSM WITH DISSECTION

Context and Impact: Aortic dissection and pulmonary embolism are two of the most common cardiopulmonary emergencies that are associated with poor prognosis and high mortality rates. Typical presentations for these conditions can vary widely from acute chest pain with severe symptoms such as shortness of breath, tachycardia, tachypnea or can present painless with mild symptoms. The appearance of saddle pulmonary embolism can rarely occur especially with intramural hematoma, and aortic dissecting aneurysm. Report of Case: A 50 years old African American female patient presents to the primary care clinic with a recent aortic dissection repair performed 4 weeks ago. She has a past medical history of hypertension and hyperlipidemia. At the clinic, she complained of sever shortness of breath, hypoxia and sinus tachycardia on EKG which led for her admission to the hospital. The patient was initially placed on 2L of oxygen via nasal cannula and basic labs with BNP and Troponins ordered. CT angiography of her chest was obtained and showed posterior aortic arch measuring 6.1 cm with increased density posteriorly that could reflect intramural hematoma/ acute dissection or dissection repair. Further investigation with a CT angiograph of her chest showed acute

bilateral segmental pulmonary emboli with saddle embolus. It also showed posterior aortic arch with increased density that was consistent with acute intramural hematoma. A referral to cardiovascular recommended placing the patient on anticoagulation, Protonix, and admission to the intensive care unit. The case was discussed with cardiothoracic surgery for a consideration for catheter thrombectomy given the risk of hematoma rupture. They did agree the patient should be started of heparin infusion and to undergo a Ekosonic Endovascular System (EKOS) procedure. It is a non-surgical treatment option that uses ultrasound and tissue plasminogen activator (tPA) to dissolve blood clots. Next day, the patient began having increasing shortness of breath and tachycardia. A bedside Ultrasound was performed and showed Inferior Vena Cava collapsibility of greater than 50%. Also, she slightly became hypotensive of which she received intravenous fluids, albumin bolus as well as normosol bolus. She began to have increasing tachycardia, tachypnea and anxiety, and which was placed on Precedex with resolution. Overnight, her hemoglobin started to drop (6.4-6.9) and was transfused 2 units of pack red blood cells. An X-ray was obtained which showed complete opacification of the left hemithorax with

underlying actelectasis or infiltrate. A repeat CT chest and pelvis angiograph showed a large left pleural effusion that developed due to aneurysm rupture, with intramural hematoma still present, and an aortic dissection extending into the right common iliac artery. The patient was transported by air to another facility to undergo a thoracic endovascular aortic repair procedure. She returned to the clinic a month later for a follow-up with a healing incision site. She had no complaints and was able to do hair daily activities with the help of a walker. Simultaneous occurrence of pulmonary embolism, intramural hematoma, and aortic aneurysm is a rare diagnosis. As these conditions can present with non-specific symptoms to hemodynamic instability based on the severity of the disease.

25 2023 Via Research Recognition Day