Aortic dissection-Pulmonary embolism association: A therapeutic dilemma

Abstract

Aortic dissection is a rare but serious condition. Its association with pulmonary embolism is exceptional and produces a real therapeutic dilemma. We are discussing the case of a 67-year-old male patient who presented with paraplegia with infectious syndrome. The chest X-ray performed to screen for an infectious site led to the suspicion of an aortic aneurysm and the CT angiography showed Stanford type B aortic dissection associated with bilateral proximal pulmonary embolism. The treatment was symptomatic and resulted in the patient's death 48 hours after diagnosis. Management of this pathological association is not standardized between establishing anticoagulant therapy and therapeutic abstention. This management depends on the teams and has a very cautious prognosis.

Keywords: Aortic dissection; Pulmonary embolism; Therapeutic dilemma.

Fig. 1

CT scan of the lumbar spine in sagittal reformation (a) and axial slice passing through L5 (b) pancake-like compression of L3 and cuneiform of L4 of at least 50% of the height of the above and underlying vertebrae. Severe narrowing of the L3-L4 interbody space with [disk void] and condensation of the adjacent vertebral endplates (black arrow). Receding of the posterior wall of L4 encroaching on the thecal sac (black arrow head). Anterior marginal [osteophytes] of L1 and L2, narrowing of the interbody spaces L1-L2 and L2-L3, and [disk void] in L1-L2 (white arrow). Fragmented, puzzle-like appearance of L4, no thickening of the perivertebral soft tissues.

Fig. 2

Frontal chest X-ray. Enlargement of the mediastinum and division of the edges of the aorta (arrow): a pattern suggestive of aneurysm and dissection of the aorta.

Fig. 3

CT angiography of the chest and abdomen, axial slice (a, c, and e); sagittal (b) and coronal (d) reformation. Massive bilateral proximal pulmonary embolism (white arrows), aortic dissection (black arrow). Stanford type B aortic dissection with an entry point in the descending thoracic aorta (black arrow); the intimal flap (white arrow) separates the true lumen (black arrow head) from the false lumen (white arrow head). The false lumen is circulating and partially thrombosed. The dissection extends to the left renal artery, which is dissected (black arrow) the right renal artery emerges from the false lumen with right renal infarction (white arrow). The exit points are located in the right common iliac artery and left common femoral artery (white arrows). Aneurysmal dilation of the thoracic-abdominal aorta measuring 76 mm in maximum diameter at the thoracic level and 56 mm at the abdominal level, depending on the false lumen, extending from the aortic arch to the suprarenal aorta.