Coexistence of Common Pathologies of the Cardiovascular System in a Patient with Pain in the Right Lower Limb

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Interesting Images Coexistence of Common Pathologies of the Cardiovascular System in a Patient with Pain in the Right Lower Limb

Paweł Ga´c 1,2,* , Martyna Hajac 2, Piotr Macek 3 and Rafał Por˛eba 3

1 Centre for Diagnostic Imaging, 4th Military Hospital, Weigla 5, PL 50-981 Wroclaw, Poland 2 Department of Hygiene, Wroclaw Medical University, Mikulicza-Radeckiego 7, PL 50-368 Wroclaw, Poland; [email protected] 3 Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, PL 50-556 Wroclaw, Poland; [email protected] (P.M.); [email protected] (R.P.) * Correspondence: [email protected]; Tel.: +48-261660480

Abstract: Deep vein thrombosis and pulmonary embolism, aortic aneurysm and aortic dissection, as well as peripheral arterial atherosclerosis, are frequently diagnosed vascular disorders. In this paper, the authors present the case of coexistence of common pathologies of the cardiovascular system in a patient with pain in the right lower limb. The presented images provide a didactically valuable overview of serious cardiovascular pathologies. This article highlights the value of computed tomography angiography in diagnosis of cardiovascular life-threatening conditions, especially as a result of proper medical interview and physical examination.

Keywords: aortic dissection; aortic aneurysm; computed tomography angiography; deep vein thrombosis; peripheral arterial atherosclerosis; pulmonary embolism

A 68-year-old man was transferred to the vascular emergency unit from a regional Citation: Gać,P.; Hajac, M.; Macek, P.; hospital where he was admitted due to pain in the right lower limb persisting for 3 days. Por˛eba,R. Coexistence of Common The anamnesis showed a history of stroke with aphasia, type 2 diabetes, persistent Pathologies of the Cardiovascular atrial fibrillation, chronic obstructive pulmonary disease (COPD) and osteoarthritis of the System in a Patient with Pain in the joints and spine. The patient denied taking any medications permanently and at that point Right Lower Limb. Diagnostics 2021, described himself as an ex-smoker. On admission, the patient reported pain in the right 11, 56. https://doi.org/10.3390/ lower limb and mild dyspnea. diagnostics11010056 Laboratory tests showed negative nasopharyngeal swab for SARS-CoV-2 (negative N2 gene for SARS-CoV-2 and E gene for the Betacoronaviridae family using the qRT- Received: 5 December 2020 × µ Accepted: 30 December 2020 PCR method), slightly increased WBCs (11.6 103 L), high CRP level (53.7 mg/L), Published: 2 January 2021 marginally reduced sodium level (134 mmol/L) and significantly elevated D-dimer level (29.36 µg/mL).

Publisher’s Note: MDPI stays neu- The ultrasound examination found deep vein thrombosis in the right lower limb. tral with regard to jurisdictional clai- Owing to clinically suspected pulmonary embolism (high D-dimer concentration and ms in published maps and institutio- presence of dyspnea), computed tomography angiography (CTA) of pulmonary arteries nal affiliations. was performed. CTA showed dilation of the right and left pulmonary arteries with a borderline width of the pulmonary trunk (pulmonary trunk diameter about 34 mm, right pulmonary artery diameter about 27 mm, left pulmonary artery diameter about 27 mm) (Figure1a). Distal section of the left pulmonary artery revealed a parietal irregular filling Copyright: © 2021 by the authors. Li- defect suggesting presence of embolic material (Figure1b). No other embolic filling defects censee MDPI, Basel, Switzerland. of arterial vessels were found. The right ventricle was normal-sized (right to left ventricular This article is an open access article diameter ratio was 0.62); no angiographic signs of right heart failure were observed (no distributed under the terms and con- signs of contrast reflux into inferior vena cava (IVC)). Based on this CTA, diagnosis of ditions of the Creative Commons At- pulmonary embolism was suggested. Additionally, CTA showed aortic dilation to about tribution (CC BY) license (https:// creativecommons.org/licenses/by/ 6.0 cm in the ascending section and non-uniform aortic density suggesting acute aortic 4.0/). syndrome (Figure1c).

Diagnostics 2021, 11, 56. https://doi.org/10.3390/diagnostics11010056 https://www.mdpi.com/journal/diagnostics Diagnostics 2021, 11, x FOR PEER REVIEW 2 of 5

Diagnostics 2021, 11, 56 2 of 5 ally, CTA showed aortic dilation to about 6.0 cm in the ascending section and non-uniform aortic density suggesting acute aortic syndrome (Figure 1c).

(a) (b)

Figure 1. Cont.

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(e) (f)

(g) (h)

Figure 1. Cont.

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(i)

Figure 1. Computed tomographyFigure angiography 1. Computed images: tomography (a) dilation of the angiography right and left pulmonary images: ( arteriesa) dilation with a of borderline the right and left pulmonary arteries with a bor- width of the pulmonary trunk;derline (b) left width pulmonary of the artery pulmonary filling defect trunk; suggesting (b) left presencepulmonary of embolic artery material; filling defect (c) non- suggesting presence of embolic material; (c) uniform aortic density suggestingnon-uniform acute aortic aortic syndrome; density (d) aneurysmsuggesting of the acute ascending aortic aorta, syndrome; aortic arch ( andd) aneurysm proximal of the ascending aorta, aortic arch and part of the descending aorta;proximal (e) aortic aneurysm part of the with descending massive parietal aorta; thrombi/aortic (e) aortic aneurysmaneurysm with with chronic massive dissection parietal thrombi/aortic aneurysm with chronic and clotting of the supposedlydissection dissected and canal; clotting (f) angular of (Gothic) the supposedly aortic arch; (dissectedg) stenosis ofcanal; the proximal (f) angular section (Gothic) of the aortic arch; (g) stenosis of the proximal h i superior mesenteric artery; (section) occlusion of the of the superior proximal mesenteric section of the artery; right superficial (h) occlusion femoral artery;of the (proximal) filling defects section in of the right superficial femoral artery; (i) the veins of the right iliac axis that is most probably a thrombotic material. filling defects in the veins of the right iliac axis that is most probably a thrombotic material. On the basis of the aortic image on CTA of the pulmonary arteries and life-threatening condition, the decision was made toOn supplement the basis diagnostics of the with aortic CTA ofimage the thoracic- on CTA of the pulmonary arteries and abdominal aorta. CTA of the aortalife-threatening showed aneurysm condition, of the ascending the decision aorta, was aortic made arch to supplement diagnostics with CTA of and proximal part of the descending aorta (maximum diameters of 6.0 cm, 3.9 cm and the thoracic-abdominal aorta. CTA of the aorta showed aneurysm of the ascending aorta, 4.9 cm, respectively) (Figure1d). From the level of the left subclavian artery (LSA) origin over the further part of the thoracicaortic aorta arch and and proximal proximal abdominal part of aorta,the descending to the level of aorta (maximum diameters of 6.0 cm, 3.9 about 2.5 cm below the renal arteriescm and origin, 4.9 cm, the vessel respectively) periphery revealed(Figure the1d). presence From the level of the left subclavian artery of wide hypodense structure(LSA) with thickness origin upover to 1/2the diameterfurther part of the of aortic the lumen;thoracic in aorta and proximal abdominal aorta, to the proximal section, the structurethe level was located of about medially 2.5 cm and below posteriorly, the renal then arteries left-sided origin, the vessel periphery revealed the and posteriorly, and in the distal section it was located both left-sided and anteriorly (Figure1e). Regarding differentiation,presence the of CTA wide image hypodense of the aorta structure could correspond with th toickness up to 1/2 diameter of the aortic aortic aneurysm with massivelumen; parietal thrombi/aorticin the proximal aneurysm section, with the chronic structure dissection was located medially and posteriorly, then and clotting of the supposedlyleft-sided dissected canal. and Moreover,posteriorly, CTA and revealed in the angular distal (Gothic) section it was located both left-sided and an- aortic arch (Figure1f), short-segmentteriorly stenosis (Figure of 1e). the proximalRegarding section differentiation, of the superior the CTA image of the aorta could corre- mesenteric artery by 50–70% of the lumen (Figure1g), occlusion of the proximal section of the right superficial femoralspond artery to (Figure aortic1h) aneurysm and filling defectswith massive in the veins pari ofetal the thrombi/aortic aneurysm with chronic right iliac axis that is most probablydissection a thrombotic and clotting material of (Figure the supposedly1i). dissected canal. Moreover, CTA revealed an- Due to development of symptomsgular (Gothic) of acute ischemia aortic inarch the right(Figure lower 1f), limb, short- the patientsegment stenosis of the proximal section of was qualified for surgical treatment.the superior Embolectomy mesenteric of the common artery femoralby 50–70% artery, of deep the lumen (Figure 1g), occlusion of the proximal section of the right superficial femoral artery (Figure 1h) and filling defects in the veins of the right iliac axis that is most probably a thrombotic material (Figure 1i). Due to development of symptoms of acute ischemia in the right lower limb, the patient was qualified for surgical treatment. Embolectomy of the common femoral artery, deep femoral artery, superficial femoral artery and popliteal artery was performed with improvement in the blood supply to the operated limb. Antithrombotic treatment was introduced. The patient was qualified for planned cardiac surgery of the ascending aortic aneurysm.

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femoral artery, superficial femoral artery and popliteal artery was performed with improvement in the blood supply to the operated limb. Antithrombotic treatment was introduced. The patient was qualified for planned cardiac surgery of the ascending aortic aneurysm. Deep vein thrombosis and pulmonary embolism, aortic aneurysm and aortic dissection, as well as peripheral arterial atherosclerosis are frequently diagnosed vascular disorders, although they do not tend to coexist [1–4]. The separate prognoses for each of these diseases are serious [1–4]. The co-occurrence of various diseases of the cardiovascular system is occasionally observed, more often in the elderly [5]. Due to this fact, increased risk of deep vein thrombosis and pulmonary thromboembolism in patients with aortic aneurysm recently became an area of investigations [6]. The presented images provide a didactically valuable overview of serious cardiovascular pathologies and based on literature review no similar case reports of such complex pathologies of cardiovascular diseases were described. This article highlights the value of CTA in diagnosis of cardiovascular life-threatening conditions, especially as a result of proper medical interview and physical examination (which revealed risk factors-persistent atrial fibrillation, dyspnea and limb pain). The partnership of radiologist and emergency physician in such cases is essential.

Author Contributions: Guarantor of integrity of the entire study: P.G., R.P.; clinical studies: P.G.; manuscript preparation: P.G., M.H., P.M.; manuscript editing: R.P. All authors have read and agreed to the published version of the manuscript. Funding: The APC was funded by Wroclaw Medical University. Institutional Review Board Statement: The manuscript contains a presentation of the description of diagnostic tests of a selected patient; the work does not describe a medical experiment-the opinion of the bioethics committee was not required. Informed Consent Statement: The patient gave his written consent to the examination and the use of the images by the researcher. Data Availability Statement: No new data were created or analyzed in this study. Data sharing is not applicable to this article. Conﬂicts of Interest: The authors declare no conﬂict of interest.

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