Type A acute aortic dissection mimicking pulmonary embolism: intramural hematoma of the pulmonary arteries causing right heart pressure overload and hemoptysis

Aim To report on an atypical complication of type A acute aortic dissection (TAAAD) mimicking pulmonary embolism with right heart pressure overload and hemoptysis due to intramural hematoma of the pulmonary arteries extending into the pulmonary interstitium.
Methods A 66-years old male presented with sudden chest pain, dyspnoea and nausea. Electrocardiogram (ECG), point of care ultrasound (POCUS) of the heart and tripple rule out computed tomography (CT) were performed to differentiate the cause of acute chest pain.
Results ECG showed no ischemia. POCUS of the heart showed aneurysmal ascending aorta (4,5 cm), suspected intimal flap, mild aortic regurgitation, minimal pericardial effusion, right heart dilatation with impaired function. CT confirmed TAAAD with extensive intramural hematoma around the central pulmonary arteries propagating to intrapulmonary branches. Additionally, there was dilatation of the right ventricle and right atrium indicative of right heart pressure overload along mild haemorrhagic pericardial effusion anterior to the right ventricle. No evidence of pulmonary embolism was found. Emergency surgery included the replacement of the supracoronary ascending aorta and aortic hemiarch. 
Conclusion TAAAD is a rare but life-threatening cause of chest pain often mimicking other conditions such as pulmonary embolism. Pulmonary complications including intramural hematoma of the pulmonic trunk due to its shared adventitia with ascending aorta are rare but clinically significant, causing lumen reduction or occlusion of pulmonary arteries, leading to right heart pressure overload. Timely differentiation is critical as anticoagulation is contraindicated.

Conceptualization, E.R.D.; Writing – original draft, E.R.D.; Data curation, L.L.; Writing – review & editing, D.C.; Supervision, S.B. All authors have read and agreed to the published version of the manuscript.