Acute aortic dissection: a missed diagnosis

Abstract

A 60-year-old man with a history of indigestion and untreated hypertension presented with sudden-onset central chest pain which radiated to his back. Acute coronary syndrome was initially suspected but excluded in the emergency department before the patient was discharged. The pain subsequently abated to mild intermittent episodes and was misdiagnosed as indigestion. A week later the patient developed new shortness of breath and 'flu-like' symptoms with a positive d-dimer test. CT angiography revealed a Stanford type B aortic dissection which was causing hypoperfusion of the right kidney, resulting in an acute kidney injury. Due to uncontrolled hypertension despite rigorous antihypertensive medication and his failing renal function, the patient underwent endovascular repair and made a good recovery postoperatively.

Keywords: cardiovascular medicine; emergency medicine; hypertension; radiology; vascular surgery.

Figure 1

Axial CT angiography of aortic arch showing dissection flap.

Figure 2

Axial CT angiography at the level of the visceral abdominal aorta showing dissection and right renal hypoperfusion.

Figure 3

TEVAR stent placement. LAO, left anterior oblique; TEVAR, thoracic endovascular aortic repair.