Pulmonary artery dissection (PAD): A very unusual cause of chest pain

Abstract

A 51-year-old African American woman with medical history of essential hypertension and chronic obstructive pulmonary disease (COPD) presented to the hospital with chest pain and shortness of breath. The chest pain was retrosternal and radiated to the back. It lasted for about an hour and resolved without any intervention. After some time, she again felt discomfort in the chest, which was a constant and dull ache.She had similar episodes of chest pain 1 week prior, although less severe in intensity, for which she went to an outside hospital before coming to our hospital. Acute coronary syndrome was ruled out with serial cardiac enzymes measurements. An exercise stress test was also performed at that time, which failed to show any stress-induced ischemia.Her medications included lisinopril for hypertension and aspirin, which had been started 1 week prior to admission. She gave a 10-pack-year history of smoking tobacco. Family history was significant for hypertension in her father and coronary artery disease in her mother at the age of 58 years. A review of systems was negative for fever, cough, orthopnea, wheezing, palpitations, nausea, vomiting, recent surgery, or any significant trauma. AssessmentThe patient's physical examination was only remarkable for a blood pressure (BP) of 181/100 mm Hg. She did not have Marfanoid features, hyperflexible joints, or easy bruisability. Laboratory tests, including complete blood count, comprehensive metabolic panel, and cardiac enzymes, were within normal limits. A contrast-enhanced computed tomography (CT) of the chest showed a linear hypodense area in the left lateral aspect of the main pulmonary trunk, which suggested an intimal dissection of the main pulmonary artery. Magnetic resonance angiography/imaging (MRA/MRI) confirmed dissection of the main pulmonary artery extending into the proximal left pulmonary artery and associated with a 12 Â 8 mm 2 aneurysm (Figures 1 and 2). The entry site of dissection was located in the main pulmonary artery just after its origin and the exit site was located in the left pulmonary artery 5 mm distal to the bifurcation of main pulmonary artery. The pulmonary artery diameter at the dissection was 27 mm. DiagnosisTo investigate possible etiologies, a transthoracic echocardiogram with Doppler was done to look for pulmonary hypertension. The echocardiogram showed normal pulmonary artery pressure with normal right ventricular systolic pressure. There was no evidence of pericardial effusion or structural cardiac abnormality on echocardiogram. Further investigations including work up for connective tissue diseases and infectious etiologies (Table 1) were normal.According to Shilkin et al., 1 Helmbrecht first reported pulmonary artery dissection (PAD) in 1842. PAD is very rare and is usually diagnosed at autopsy. There are 71 other cases of PAD reported in the English literature, of which 16 cases are in living patients. 2-17 Unlike aortic dissection, which is fairly common, the reentry circuit for PAD is formed by the rupture of the free wall ...

Etiological classification and manifestation of pulmonary artery dissection: A literature review and case analysis

“…Prior studies have demonstrated that PAD is strongly associated with chronic pulmonary hypertension due to structural cardiac defects, either congenital or acquired [ [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] ]. Chronic pulmonary hypertension results in dilatation of the pulmonary artery trunk, leading to susceptibility to media degeneration and subsequently dissection.…”

“…The group of non-CHD associated-PH included idiopathic pulmonary arterial hypertension (19 cases) [ 2 , 22 , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] ], chronic obstructive pulmonary disease (8 cases) [ 1 , 9 , 10 , 37 , [39] , [40] , [41] ], pulmonary hypertension associated with liver disease (4 cases) [ 37 , 42 , 43 ], and pulmonary thromboembolic disease (3 cases) [ 44 , 45 ] ( Fig. 4 C).…”

Women with sudden cardiac arrest

“…Medical treatment aims to reduce right ventricle preload and afterload. Medications for reduced pulmonary hypertension, such as endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and soluble guanylate cyclase stimulants, are helpful 2,4 . No consensus treatment guidelines have been developed, but surgical management or medical management followed by surgery seems to be slightly better than medical management alone 2 …”

Rare Presentation of Left Lower Lobe Pulmonary Artery Dissection

“…In most cases the final diagnosis is made only postmortem. The major complications of PA dissection leading to the death of the patient are cardiac tamponade and haemopericardium [1, 2]. Most common acute symptoms include dyspnoea, chest pain, and central cyanosis [3].…”

“…Other rare causes include chronic inflammation of the pulmonary arteries, right heart endocarditis, amyloidosis, trauma, and severe atherosclerosis [6]. In some cases, the cause of pulmonary arterial dissection remains unknown [2, 7]. Pulmonary artery dissection with intimal flap calcification is very rare.…”