A 72-year-old patient, independent for basic activities of daily living, with cardiovascular risk factors, type 2 diabetes, COPD, and dyslipidemia. His relatives found him on the floor of his home with a decreased level of consciousness, unresponsive to stimuli.  

Five days earlier, he had consulted the emergency department for chronic pain in both upper limbs with paresthesia and decreased strength that had worsened in the last 48 h. A diagnosis of acute chronic arterial ischemia had been made and treatment with acetylsalicylic acid and pentoxifylline was prescribed. 

For his current symptoms, investigations show acute ischemic stroke with massive PE. 

What would be your therapeutic approach and in which order?

For your information, these were the other investigation results -

• Blood tests: hemogram with chronic polyglobulia. Coagulation screen without alterations. Elevated D-dimer. Antiplatelet factor IV antibody: negative. 

• Cranial CT: loss of differentiation of gray substance-white substance with a blurring of furrows and hypodensity at the level of the vascular territory of the left PCA. 

• Angio-CT: thrombosis at the level of the left subclavian artery, stop at the level of left PCA, repletion defects extending to the level of the left vertebral artery, and subocclusive thrombus at the level of the basilar artery are identified. Repletion defect in pulmonary arteries, compatible with massive pulmonary thromboembolism. 

• Perfusion: an area of penumbra is observed at the level of the vascular territory of the left PCA.

I have an update on my previous case (https://www.g-med.com/page/view-post?id=198754) - the 55 year old patient with colon cancer on his third cycle of capecitabine and oxaliplatin chemotherapy, who presented with chest discomfort and dyspnoea. An aortic thrombosis was found on CT incidentally. 

After consultation, we decided to initiate low-molecular-weight heparin therapy and temporarily suspended his chemotherapy. We have also tested for hypercoagulable disorder but have not found evidence of any. Another CT coronary angiography of the chest shows no indication of embolic complications.

What is the ideal duration of anticoagulation therapy for a patient diagnosed with aortic thrombosis and cancer?  

A patient aged 55 with stage III colon cancer presents with chest discomfort and dyspnoea. He is currently on day 13 of cycle 3 of capecitabine and oxaliplatin chemotherapy. There was an incidental discovery of aortic thrombosis affecting the descending thoracic aorta made through a CT scan. Subsequent investigations did not indicate any indications of aortic dissection, and CT angiography of the chest did not reveal any proof of pulmonary embolism. He did not have any prior medical records indicating the presence of coronary artery disease or hypercoagulable conditions.

Are there any special considerations in managing aortic thrombosis in a patient receiving chemotherapy? How should we change his chemotherapy management?  

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