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Aortic dissection (CTPA)

Case contributed by Assoc Prof Craig Hacking

Presentation

Acute chest pain and diaphoresis. Two years post aortic root repair and AVR. On NOACs. Borderline hypotension. Query PE verses dissection verses repair complication.

Patient Data

Age: 70 years
Gender: Male
CT

CTPA

Initial study protocolled as a combination CTA/CTPA. On finding extensive descending aortic dissection extending into the abdominal aorta and left common carotid artery, further CTA was performed of the neck, abdomen and pelvis as well as a ECG-gated CTA of the aortic root.

The CTPA is of good quality and no pulmonary embolus is identified. No signs of right ventricular strain.

Sternotomy wires. No pericardial effusion.

Marked kyphoscoliosis. Advanced multilevel vertebral degenerative disease.

CT

CTA

Vascular findings

Acute aortic dissection arising in the lateral wall of the aortic arch at the level of the left common carotid origin (Stanford A) and terminates beyond the abdominal aortic bifurcation in the common iliac arteries:

  • The dissection flap extends inferiorly into the left common carotid artery up to the carotid bifurcation. No ICA involvement demonstrated.
  • No involvement of the brachiocephalic trunk or left subclavian artery (which are supplied by the true lumen).
  • The major flap arises just beyond the origin of the left subclavian artery and demonstrates a perforation in the distal arch.
  • The lateral wall of the arch is thickened, which may indicate intramural hematoma. There is a small amount of adjacent perivascular mediastinal fat stranding.
  • The ECG-gated aortic root phase does not indicate any dissection of the ascending aorta. Aortic valve replacement noted.
  • The true lumen is almost completely compressed in the distal descending aorta and as it passes through the diaphragm.
  • In the upper aspect of the abdominal aorta the false lumen almost completely encases the central true lumen.
  • The origin of the celiac trunk appears to be supplied by both the true and false lumens. The celiac trunk is ectatic (13 mm) but there is no evidence of dissection into it.
  • The true lumen supplies the SMA, left renal artery and IMA. No evidence of dissection into these vessels.
  • The false lumen supplies the right renal artery and there is evidence of a small dissection flap in the mid vessel. There is reduced density in the right kidney indicating altered perfusion.
  • The dissection extends inferiorly past the aortic bifurcation into the CIAs which are aneurysmal.
  • On the right the dissection terminates at the common iliac artery bifurcation, with the true lumen supplying both the external and internal iliac arteries. The CIA is aneurysmal (2.5cm)
  • On the left the dissection extends through the common iliac artery into both the internal and external iliac arteries. The left external iliac artery false lumen is almost completely thrombosed distally. The CIA is aneurysmal (2.9cm.)

Other findings

No intracranial arterial occlusion or dissection.

Sternotomy wires. No pericardial effusion.

Posterolateral bladder wall diverticuli. Low-lying left kidney. Cortical scarring of both kidneys. Fluid-filled stomach and proximal esophagus, placing the patient at risk of aspiration. Streaky opacification of the lower lobes which may be due to aspiration.

Bilateral inguinal hernias containing small bowel on the right and large bowel on the left, no bowel dilatation to suggest obstruction.

Marked kyphoscoliosis. Advanced multilevel vertebral degenerative disease.

IMPRESSION

Acute Stanford A aortic dissection extending into the right CCA and bilateral iliac arteries.

Case Discussion

The patient was transferred urgently to the cardiothoracic surgical unit at a nearby hospital.

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Case information

rID: 75506
Published: 8th Apr 2020
Last edited: 25th Oct 2020
System: Vascular, Chest
Inclusion in quiz mode: Included

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