Type B Aortic Dissection

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Case Presentation - April 2013

W. Michael Park, MD

Brief

Emergent treatment of descending thoracic aortic dissection causing kidney failure and severe hypertension treated with a complex endovascular approach.

The patient is a 51 year old man with prior history of difficult to control blood pressure and smoking who presented to an outside institution about a week prior to presentation with severe chest pain associated with shortness of breath. At presentation there, his blood pressure was 248/119. CT scan (figure 1) revealed a descending thoracic aortic dissection. He had acute renal failure with an elevated creatinine that peaked at 2.4mg/dL. His blood pressure was eventually controlled on a 5 drug regimen which included clonidine, Cozaar, Coreg, hydralazine, and amlodipine. Despite this, his blood pressure remained persistently above 160mmHg systolic, and he had persistent back pain. His renal function stabilized at a creatinine of 1.8, indicating that he had lost almost 50% of his baseline kidney function. He was going to be discharged for medical management of his dissection. He requested a second opinion here at Cleveland Clinic and he was transferred by air.

On arrival, his blood pressure remained above 160mmHg and he remained symptomatic of back pain. I reviewed his CT scan and saw that he had compressed most of his true lumen, and this compromised flow into the kidneys which were perfused by the false lumen. He also had diminished flow lumen into his abdominal viscera (stomach, liver, intestines) and legs, although he remained asymptomatic in these vascular beds. His continued back pain concerned me because this could herald eventual rupture if his blood pressure remained high. Long term, this was a consideration as well and the fact that he was young meant that he was most likely to suffer the side effects on taking many blood pressure medications – including lethargy, depression, and impotence.

Case Slides

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Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7

Reviewed: 11/13

Non-critical demographic information has been changed to protect the anonymity of the individual and no association with any actual patient is intended or should be inferred.

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