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Aortic dissection

Aortic dissection

A breach in the integrity of the aortic wall allows arterial blood to enter the media, which is then split into two layers, creating a “false lumen“ alongside the existing or “true lumen“. The primary event is often a spontaneous or iatrogenic tear in the intima of the aorta. Disease of the aorta and hypertension are the most important aetiological factors. The aortic dissection is a relatively rare condition, but it may rupture and have fatal consequences. The case report describes a dissection of the descending aorta in a 55-year-old patient.

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Anamnesis:

55-year-old patient with a history of arterial hypertension, an active smoker, with a history of smoking of 10 cigarettes a day for 30 years (15 packyears). Brought to the hospital by an ambulance, at first examined at a neurological outpatient clinic for thoracic and lumbal spine pain. For arterial hypertension (BP 200/90 mmHg) sent for examination to internal outpatient clinic. The patient reported an increased physical activity in recent days. For about 3 days he coughed, he caught a cold. The day before the examination, he wanted to tie laces on his shoes and after he leaned forward, he felt a pain in his lumbal spine. Since then, he felt the pain in his lumbal spine and also between the shoulder blades, the pain worsened when he was breathing. The pain radiated to the abdomen, it was more pronounced during lying and sitting, so the patient could not sit, he felt better when he was walking. The pain did not burn in the lower limbs. After analgesic treatment at home and subsequently given in the ambulance, at the neurological and internal outpatient clinic (Dorsiflex, Flector, Mesocain, Analgin, Novalgin, Almiral), the pain did not relieve. Patient without cephalea, vertigo, nausea, vomiting, chest pain, palpitations, with normal appetite and normal anovesical features.

Physical examination: BP left upper extremity 193/103 mmHg, BP right upper extremity 187/99 mmHg
Patient conscious, oriented in place, time and person, active position, normostenic habitus, excessive nourishment, skin without jaundice and cyanosis, eupnoic, without lateralisation. Pupils isocoric, bilateral fotoreaction, anicteric eyeballs, pink conjunctivas, tongue in a mid position, dry, uncovered, normal and symmetrical jugular vein filling, non-palpable lymphatic nodes and thyroid gland, symmetrically palpable pulsation of carotid arteries. Vesicular breathing, frontally spastic, regular heart rate, fr.82 / min, abdomen without pain and resistance during palpation, non-palpable liver and spleen, tapottement bilaterally negative, lower extremities without oedemas, pulsations on a. femoralis, a. dorsalis pedis, a. tibialis posterior bilaterally symmetrically palpable.

ECG: sinus rhythm, fr. 85/min., PQ 140 ms, QRS 90 ms, QT 360 ms, ST without elevation/depression, R/S at V5, T pozit., without ectopy.

Laboratory results:

CK 4,21 ukat/l*, CK-MB 0,25 ukat/l, TnI 0,012 ug/l, D-dimér 0,67 mg/l*, CRP 49,11 mg/l*, WBC 10,06x109/l*, the rest of lab. tests normal.

Differential diagnosis:

- Aortic dissection
- Acute coronary syndrome
- Aortic aneurysm
- Aortic regurgitation
- Pericarditis
- Musculoskeletal pain
- Mediastinal tumor
- Pleuritis
- Pulmonary embolism
- Cholecystitis

Imaging methods:

CT aortography (Figure 1, 2) – Dissection of descending aorta, type Stanford B/DeBakey III/- from aortal isthmus below the branch of a. subclavia l. sin. formation of intimal flap, the dissection ends 15 mm above the branch of truncus coeliacus. Dissection formates “true“ and “false“ aortic lumen. Branches of truncus brachiocephalicus, a. carotis l. sin., a. subclavia l. sin., truncus coeliacus, a. mesenterica superior, a. mesenterica inferior, aa. renales, aa. iliacae with appropriate filling. At aortic arch the width of aortic wall 9 mm, probably intramural hematoma.

Therapy:

Treatment is urgently required. Initial management comprises pain control and antihypertensive treatment. The aim of medical management is to maintain a mean arterial pressure of 60-75 mmHg to reduce the force of the ejection of blood from left ventricle. Type B dissections are treated medically unless there is actual or impending external rupture, or vital organ (gut, kidney) or limb ischaemia, as the morbidity and mortality associated with surgery is very high. Percutaneous or minimal access endoluminal repair is sometimes possible and involves either ,,fenestrating“ (perforating) the intimal flap so that blood can return from the false to the true lumen (so decompressing the former), or implanting a stent graft placed from the femoral artery (our patient). After surgery, the increase in blood pressure and the increase in tension in the aortic wall should be avoided, which usually requires a combination of antihypertensive drugs. It is also necessary to avoid excessive physical strain and to monitor the dilatation in the area of aneurysm, extension of dissection or pseudoaneurysm formation at suture sites using imaging methods (CTA, MRA).

Discussion:

The purpose of this case report was to point out that although the following three symptoms are typical for the diagnosis of aortic dissection: sudden pain, peripheral artery pulsation deficits, and side-pressure difference in the upper extremities, in medicine is often, that not all symtoms may be present. Since in this case the dissection started below the branch of a. subclavia l. sin., we did not notice a significant difference in pressure on the upper extremities and as it ended above the branch of truncus coeliacus, aa. iliacae had adequate filling and the pulsations in the peripheral arteries were symmetrically palpable.

Authors declare the case report will not be published in any national or international publications.

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Creative Commons LicenseContribution content is subject to licence Creative Commons Uveďte autora-Neužívejte dílo komerčně-Nezasahujte do díla Attribution 3.0 Czech Republic
author: Katarína Demková, Jana Grofčíková | organization: Department of Vascular Surgery | published on: 1.1.2018 | last modified on: 30.4.2018
citation: Demková Katarína, Jana Grofčíková: Aortic dissection. Multimedia support in the education of clinical and health care disciplines :: Portal of Faculty of Medicine [online] 2018-01-01, last modif. 2018-04-30 [cit. 2018-11-19] Available from WWW: <http://portal.lf.upjs.sk/articles.php?aid=342>. ISSN 1337-7000.
 

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