Masquerade presentation of acute type B aortic dissection as isolated acute limb ischaemia treated with endovascular fenestration with angioplasty: A case report

Abstract

Introduction and importance: Masquerade presentation of acute type B aortic dissections (TBAD) as acute limb ischaemia (ALI) is rare. Holistic clinical assessment, preferably with the help of scoring systems and timely computer tomographic angiogram (CTA), is needed for early diagnosis. Acute TBAD and its complications are increasingly treated with endovascular therapies.

Case presentation: A 21-year-old male with poorly controlled essential hypertension was admitted with prominent clinical features of ALI. No clinical pointers of a TBAD were present. Doppler ultrasound revealed an arterial occlusive pattern, and an urgent surgical embolectomy was performed. On failure to retrieve any thrombi, a CTA was performed, and diagnosis of TBAD complicated with ALI was made. The limb was revascularised with guidewire directed aortic fenestration with angioplasty. TBAD was managed conservatively.

Clinical discussion: We report a case of acute TBAD presented as isolated ALI, which was initially diagnosed and treated as an ALI unrelated to aortic dissection. TBAD with typical or atypical clinical features presented with ALI as a malperfusion syndrome is not uncommon. However, masquerade presentations of TBAD as ALI are rare in the literature. Endovascular fenestration with or without stenting has fewer neurological complications and long-term mortality than thoracic endovascular aortic repair (TEVAR). Moreover, they become convenient in resource-poor settings without dedicated aortic centres.

Conclusion: Masquerade presentation of TBAD should be recognised in the differential diagnosis of ALI. Timely CTA would prevent unnecessary interventions and help diagnose TBAD complicated with ALI. Despite their availability, outcomes will depend on proper patient selection for endovascular, surgical, and TEVAR options.

Keywords: Acute limb ischaemia; Acute type B aortic dissection; Angioplasty; Case report; Endovascular fenestration; Malperfusion syndrome.

Fig. 1

CT angiogram (axial view) following embolectomy A) type B aortic dissection with a spared arch of aorta and its branches [red arrow shows the true and false lumen] B) bilateral intact renal arteries C) aortic bifurcation [red arrow shows occluded false lumen with patent collateral to left lower limb] D) bilateral common iliac arteries [red arrow shows left artery with occluding thrombus]. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

CT angiogram (coronal view) A) 3D reconstruction B) 2D image showing abrupt cut off from aortic bifurcation to the left common iliac artery. Note intact coeliac, superior and inferior mesenteric as well as renal arteries.

Fig. 3

Digital subtraction angiography (DSA) and balloon dilatation A) pre-angioplasty film showing filling defect beyond left common iliac artery B) guidewire directed fenestration C) 6 mm × 80 mm balloon dilatation D) 10 mm × 80 mm balloon dilatation.

Fig. 4

Post angioplasty DSA A), B) & C) shows the successful revascularisation without a stent.

Fig. 5

Follow up CTA in 2 months. A) Coronal cut shows a short segment narrowing in the false lumen of the distal aorta with contrast run-off in the left common iliac artery and its branches B) a cross-sectional image [The red arrow shows enhancement of the previously occluded left common iliac artery. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)