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Thrombus risk versus bleeding risk: a clinical conundrum.

Elisabeth Ng¹, Adel Ekladious², Luke P Wheeler³

¹Alfred Health, Melbourne, Victoria, Australia.

BMJ Case Reports

|March 11, 2019

Summary

A rare case of simultaneous aortic dissection and extensive pulmonary emboli (PE) in a patient with chronic kidney disease highlights diagnostic and management challenges. This dual vascular emergency required careful anticoagulation and blood pressure control, complicated by renal impairment.

Keywords:

adult intensive care contraindications and precautions medical management pulmonary embolism vascular surgery

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Area of Science:

Cardiology
Vascular Surgery
Nephrology

Background:

A 62-year-old male with hypertension, osteoporosis, and chronic kidney disease presented with dyspnea and pleuritic chest pain.
History of focal segmental glomerulosclerosis with relapsing nephrotic syndrome complicated management.

Observation:

Physical examination revealed a loud palpable P2 and displaced apex beat.
ECG showed sinus tachycardia, right-bundle branch block, and p-pulmonale.
CT pulmonary angiogram and aortogram identified extensive bilateral pulmonary emboli and descending thoracic aortic dissection.
Lower limb ultrasound confirmed extensive, non-occlusive deep vein thrombosis.

Findings:

The patient presented with a rare combination of acute aortic dissection and extensive bilateral pulmonary emboli.
Management involved therapeutic anticoagulation and strict blood pressure control.
Surgical intervention was deferred due to worsening renal function and supratherapeutic anticoagulation.

Implications:

The co-existence of aortic dissection and pulmonary embolism is rarely described, posing significant diagnostic and therapeutic challenges.
Optimal management strategies for this dual vascular emergency remain unclear and require further investigation.
This case underscores the complexity of managing cardiovascular emergencies in patients with significant comorbidities, particularly chronic kidney disease.