Presentation
Sudden onset of abdominal pain while straining, low back pain, and chest pain. No significant past medical history.
Patient Data
Aortic dissection with an entry point in the aortic arch. Dissection extends in a retrograde direction to the aortic root and an antegrade direction through the descending thoracic and abdominal aorta with the false lumen continuing into the left internal iliac artery. The left and right coronary arteries emanate from the smaller true lumen and are well opacified. The true lumen supplies the right common carotid artery and the left common carotid artery. The dissected true and false lumina extend through the visualized portion of the left subclavian artery and left vertebral artery. The true lumen supplies the right subclavian artery and right vertebral artery.
The dissection occupies the left lateral aspect of the thoracic aorta before curving posteriorly through the abdominal aorta. The true lumen supplies the celiac trunk, SMA, right renal artery, IMA, left external iliac, and, right common, external/internal iliac artery.
The false lumen extends into the proximal left renal artery however there is good opacification in the mid to distal renal artery indicating communication with the true lumen. There is only mildly reduced renal parenchymal enhancement. The false lumen supplies all the resolvable lumbar arteries, the posterior aspect of the left common iliac artery and the left internal iliac artery.
Relatively hyperdense hematoma (59 HU) surrounds the pulmonary trunk and left and right proximal pulmonary arteries causing moderate to severe bilateral proximal pulmonary artery stenosis. Mild fat stranding in the perivascular mediastinum. Small hemopericardium.
Case Discussion
Post CT, the patient was commenced on a labetalol infusion and was rushed to emergency theater.
Intraoperative findings: acute type A dissection, severe aortic regurgitation, true lumen severely compressed by false lumen with cardiogenic shock secondary to cardiac tamponade. The initial repair was performed with the native valve resuspended in an interpositional graft. Complicated by significant bleeding/coagulopathy, the patient was transferred to intensive care with an open chest for hemostasis.
The patient was taken to theater again 2 days later for washout and closure of sternotomy wound. He was monitored in intensive care and was transferred to the ward after 5 days and subsequently discharged home within 10 days.
Two potentially fatal hemodynamic complications were present:
acute hemopericardium which can cause cardiac tamponade and prevent the filling of the right heart chambers
hemorrhage into the shared aortopulmonary sheath which can obstruct the pulmonary circulation 1
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