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• Instead of compression by haematoma, occlusion by a thrombus can be the complicating factor
  Oscar M Jolobe
  Published on: 30 October 2007

• Published on: 30 October 2007

  Instead of compression by haematoma, occlusion by a thrombus can be the complicating factor

  • Oscar M Jolobe, Retired Geriatrician

  Dear Editor,

  In the context of involvement of the right pulmonary artery by aortic dissection, instead of being caused by extrinsic compression attributable to a haematoma(1)(2)(3), obstruction of the right pulmonary artery might be attributable to thrombosis, with associated extrinsic compression by a massively dilated aorta, as shown in the instance of a 69 year old man who initially presented with stigmata of...

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  Dear Editor,

  In the context of involvement of the right pulmonary artery by aortic dissection, instead of being caused by extrinsic compression attributable to a haematoma(1)(2)(3), obstruction of the right pulmonary artery might be attributable to thrombosis, with associated extrinsic compression by a massively dilated aorta, as shown in the instance of a 69 year old man who initially presented with stigmata of pulmonary embolism including chest pain, dyspnoea, severe hypotension, and raised levels of D-dimer. In addition, through the medium of pulmonary artery digital subtration angiography, there was documentation of right pulmonary artery thrombosis with total peripheral avascularity. In view of his poor haemodynamic status thoracotomy was undertaken with a view to performing surgical thrombectomy. At operation, however, he was found to have, not only a large thrombus in the right pulmonary artery, but also an acute dissection of the ascending aorta. Extrinsic compression of the right pulmonary artery had also occured, immediately distal to its origin, but this was attributable to the massively dilated ascending aorta. Evidence of associated pulmonary embolism(PE) was obtained post-operatively when a ventilation/perfusion scan showed multiple mismatched ventilation/perfusion defects in the right lung, compatible with residual obstruction of distal branches of the right pulmonary artery(4). The occasional co-existence of PE and aortic dissection is also exemplified by a 74 year old man who presented with dyspnoea, and in whom spiral computed tomography demonstrated PE involving the right pulmonary artery, as well as thrombosed dissection of the abdominal aorta.

  Comment:-
  The irony of the overlap between stigmata of PE and those of aortic dissection, and the occasional co-existence of the two disorders is that, with the exception of exploratory thoracotomy(4), their therapeutic stategies are mutually incompatible. No wonder it was the considered opinion of Sir William Osler that "There is no disease more conducive to clinical humility than aneurysms of the aorta"(4)

  References

  1) Stougiannos PN., Mytas DZ., Pyrgakis VN
  The changing faces of aortic dissection: an unusual presentation mimicking pulmonary embolism
  Heart 2007:93:1324

  2) Nasrallah A., Goussous Y., El-Said G., Garcia E., Hall RJ
  Pulmonary artery compression due to acute dissecting aortic aneurysm: a clinical and angiographic diagnosis
  Chest 1975:67:228-230

  3) Charnsangavej C
  Occlusion of the right pulmonary artery by acute dissecting aortic aneurysm
  American Journal of Roentgenology 1979:132:274-6

  4) Neri E., Toscano T., Civelli L et al
  Acute dissecting aneurysm of the ascending thoracic aorta causing obstruction and thrombosis of the right pulmonary artery
  Texas Heart Institute Journal 2001:28:149-151

  5) Gupta R., Uhrbrock D., Burnbaum Y
  Images in cardiology: Coexisting pulmonary embolism and abdominal aortic dissection
  Clinical Cardiology 2003:26:395

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  Conflict of Interest:
  None declared.

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