Aortic dissection

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:

Differential diagnosis:

Imaging methods:

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:

Authors declare the case report will not be published in any national or international publications.

4-D assessment:

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