P060: AORTIC EMERGENCY: DISSECTING THE CONNECTION BETWEEN HYPERTENSION AND AORTIC DISSECTION TYPE B
Geraldine Sequeira Grass, DO1; Guillermo Loyola, OMSIII2; Daniel Cintron Jr., DO1; William A Perez, MD1; Jose U Sanchez, MD1; 1Palmetto General Hospital; 2Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine
Introduction: An aortic dissection is a critical medical situation that demands prompt attention. Aortic dissections can be divided into types A and B based on the Stanford classification. Type A involves the ascending aorta and may progress to involve the arch and thoracoabdominal aorta while type B involves the descending thoracic or thoracoabdominal aorta distal to the left subclavian artery without the involvement of ascending aorta.1 The condition results from a tear in the innermost layer of the aorta, dividing it into two parts: a true lumen and a false lumen. A CT angiography (CTA) is used to diagnose the condition if there are clinical suspicions. The patient's survival depends on timely intervention with pharmacological treatment and possible surgical management.
Case description: A 46-year-old male with a significant past medical history of uncontrolled hypertension presented to the emergency department with a ripping sensation type chest pain and shortness of breath. The patient’s vitals upon arrival were 220/147 mmHg in which he was immediately taken for a CTA chest and abdomen/pelvis which was notable for aortic dissection type B extending from the posterior aspect of the aortic arch down to the level of the left common iliac artery. It was also noted that the celiac axis, left renal artery, and the inferior mesenteric artery were supplied by the false lumen. The patient was found to be in renal failure with elevated creatinine at 9.7, and transaminitis with AST at 87 and ALT at 292. Troponin was positive at a peak of 0.253 and brain natriuretic peptide (BNP) of 30,300. Vascular surgery was consulted due to the extent of the aortic dissection, and initially it was recommended to continue medical treatment with esmolol drip and nicardipine drip. Case was discussed in a multidisciplinary fashion with vascular surgery, nephrology, and cardiology in which it was decided to take the patient to the operating room for aortic dissection type B correction as there was an indication for repair to reduce the risk of acute degeneration or rupture, as well as increased perfusion to his viscera. The patient underwent a left common carotid to left subclavian artery bypass with graft, endovascular repair of thoracic aortic dissection using a proximal stent covering the left subclavian artery with distal bare metal extension, and placement of a temporary hemodialysis catheter into the left common femoral vein due to renal failure. The patient tolerated the procedure well without any complications. Over the course of the hospital stay, the patient was transitioned from anti-hypertensive medications through IV drips to oral medications. Unfortunately, due to long-standing history of uncontrolled hypertension as well as damage from aortic dissection, the patient’s renal function did not recover and was soon after discharged requiring hemodialysis outpatient.
Discussion: This case exemplifies the need for timely recognition and intervention of a complicated type B aortic dissection to reduce morbidity and mortality associated with this condition.
- Vilacosta I, San Román JA: Acute aortic syndrome. Heart. 2001, 85:365-8. 10.1136/heart.85.4.365