Delayed Surgical Management of Acute Type A Aortic Dissection in a Patient with Recent COVID-19 Infection and Post-COVID-19 Bronchopneumonia-Case Report and Review of Literature

Abstract

Ever since it was first described in 1760, acute type A aortic dissection has created difficulties in its management. The recent COVID-19 pandemic revealed that extrapulmonary manifestations of this condition may occur, and recent reports suggested that aortic dissection may be amongst them since it shares a common physiopathology, that is, hyper-inflammatory syndrome. Cardiac surgery with cardiopulmonary bypass in the setting of COVID-19-positive patients carries a high risk of postoperative respiratory failure. While the vast majority accept that management of type A aortic dissection requires urgent surgery and central aortic therapy, there are some reports that advocate for delaying surgery. In this situation, the risk of aortic rupture must be balanced with the possible benefits of delaying urgent surgery. We present a case of acute type A dissection with COVID-19-associated bronchopneumonia successfully managed after delaying surgery for 6 days.

Keywords: COVID-19; bronchopneumonia; cardiopulmonary bypass; malperfusion syndrome; respiratory failure; type A aortic dissection.

Figure 1

(A) Chest XR at presentation showing bilateral alveolar infiltrates, with both central and peripheric distribution in the inferior two-thirds of both lungs (more important on the right)—suggesting an infectious pulmonary disease; (B) chest XR at discharge showing resolution of pulmonary lesions; (C,D) computed tomography aspect of the lungs at presentation resembling multiple, bilateral areas of consolidation, with air bronchogram included and areas of ground-glass attenuation with a mainly central distribution, in the two-thirds of both pulmonary parenchyma (more significant in the right lung) suggesting an infectious pneumonia; (E,F) computed tomography aspect of the lungs at discharge with resolution of initial lesions.

Figure 2

CT showing intimal flap at the level of the ascending aorta, aortic arch, thoracic and abdominal aortas and superior mesenteric artery. Celiac trunk with origin in a small true aortic lumen.

Figure 3

Arch anomaly—arteria lusoria and common origin of the innominate artery and left common carotid artery.

Figure 4

Intimal flap present in all the supra-aortic vessels.

Figure 5

Small true lumen of the abdominal aorta at the origin of the celiac trunk, and protruding false lumen with a “double” intimal flap at this level.

Figure 6

CT 3D reconstruction (left) and axial image (right) of the celiac trunk originating from the true lumen of the abdominal aorta, with an increased diameter and no compression compared to preoperative settings.

Figure 7

Chest XR at day 6 showing progression of pulmonary lesions suggesting superimposed pulmonary edema.