Thrombus risk versus bleeding risk: a clinical conundrum

BMJ Case Rep. 2019 Mar 8;12(3):e228344. doi: 10.1136/bcr-2018-228344.


A 62-year-old man presented to the Emergency Department with dyspnoea and central pleuritic chest pain radiating posteriorly to between the scapulae. His medical history included hypertension, osteoporosis and chronic kidney disease secondary to focal segmental glomerulosclerosis with relapsing nephrotic syndrome. Significant examination findings included a loud palpable P2 and a displaced apex beat. An ECG revealed sinus tachycardia with a right-bundle branch block and p-pulmonale. A CT pulmonary angiogram and aortogram demonstrated extensive bilateral pulmonary emboli and a descending thoracic aortic dissection. Subsequent ultrasound of the lower limbs confirmed an extensive, non-occlusive deep vein thrombosis in the right calf. Management of this patient involved therapeutic anticoagulation and tight blood pressure control, with plans for surgical repair delayed due to worsening renal impairment and subsequent supratherapeutic anticoagulation. Co-existence of an aortic dissection and PE has been rarely described and optimal management remains unclear.

Keywords: adult intensive care; contraindications and precautions; medical management; pulmonary embolism; vascular surgery.

Publication types

  • Case Reports

MeSH terms

  • Anticoagulants / therapeutic use
  • Antihypertensive Agents / therapeutic use
  • Aortic Dissection / etiology
  • Aortic Dissection / therapy*
  • Glomerulosclerosis, Focal Segmental / complications*
  • Humans
  • Hypertension / etiology
  • Male
  • Middle Aged
  • Nephrotic Syndrome / complications*
  • Osteoporosis / etiology
  • Pulmonary Embolism / etiology
  • Pulmonary Embolism / therapy*
  • Renal Insufficiency, Chronic / etiology
  • Risk Factors
  • Venous Thrombosis / etiology
  • Venous Thrombosis / therapy*


  • Anticoagulants
  • Antihypertensive Agents