Imaging diagnosis
Case 241
【Progress】
She received life-saving procedure such as heart massage, puncture of pericardial effusion and vasopressor boost agents of adrenalin, steroid hormone.
Regrettably, she passed away several hours later.
【Discussion】
Aorta mural composes of intima, media and adventitia. Aortic dissection arises from tear of intima. Blood enter into tore intima and propagate anterograde along with aortic blood flow. Aortic dissection can propagate to arch, abdominal aorta and iliac arteries. In case of dissection in ascending aorta, tear most occurs at the site within 10cm from aortic valve. Aortic dissection propagates not only anterograde but also retrograde, inducing pericardium hematoma.
Acute thoracic Aortic dissection occurs with the incidence of 3-15/100000 per year (1-4). The population of Hannan city is approximately 55000, indicating for aortic dissection to occur 1 or 7 cases per year.
There are two classifications of aortic dissection: DeBakey I, II, III and Stanford A, B. DeBakey I includes intimal tear occurs at ascending aorta and dissection propagates beyond ascending aorta, Debakey II includes intimal tear occurs at ascending aorta and dissection is confined within ascending aorta, DeBakey III includes intima originates beyond left subclavian artery and propagates to distal. Meanwhile, Stanford A includes aortic dissection involves ascending aorta and Stanford B aortic dissection does not ascending aorta. Namely, Stanford A indicates DeBakey I and II, Stanford B indicates DeBakey III. The occurring percentage is 60% in DeBakey I, 10-15% in DeBakey II and 25-30& in DeBakey III, indicating Stanford A, 70-75% and Stanford B, 25-30% (1-4).
The prognosis of aortic dissection is still poor or challenging. The main reason for poor prognosis is mal-perfusion to systemic organs of brain, heart, digestive organs and kidneys. The incidences of mal-perfusion with aortic dissection are 7.8 % in cerebral mal-perfusion, 6.4 % in coronary mal-perfusion, 2.8% in renal mal-perfusion, 2.4% in mesenteric mal-perfusion and 6.4%, in limb ischemia (5-7). Of these, mesenteric mal-perfusion is the most devastating condition for the treatment of acute Stanford A type aortic dissection (5).
Aortic dissection is developed by hypertension, bicuspid aortic valves, connective tissue disease such as Marfan syndrome and Ehlers Danlos syndrome. First, it is crucial to control hypertension to avoid this devastating disease.
Meanwhile, pericardial effusion or hematoma occurs in various diseases and conditions: malignant disease, infections, myocardial infarction, aortic dissection, medicines, uremia and hypothyroidism. When CT level of pericardial fluids is 35 or greater, pericardial hematoma rather than pericardial effusion should be listed.
In our case, our patient experienced sudden lumbago first followed by abdominal pain and finally fell into shock. As a result, it is thought that clinical symptoms emerged along with propagation of the aortic dissection: mal-perfusion to lumbar artery, superior mesenteric artery and finally rupture from ascending aorta to pericardial space, leading to cardiac tamponade.
【Summary】
We presented a seventy two-year-old female suffering from right lower abdominal pain following lumbar pain early in the morning. Medical findings revealed no bowel sound and hard abdomen, suspecting perforation of digestive organ. Chest & abdomen CT showed pericardial hematoma, aortic dissection, small diameter of superior mesenteric artery, implying diagnosis Stanford A (DeBakey I type) aortic dissection with mal-perfusion od superior mesenteric artery and cardiac tamponade. It is borne in mind that aortic dissection of Stanford A is up to 75% and DeBakey I type is around 60%. Of mal-perfusions of cerebral, coronary, mesenteric, renal and limb, mesenteric mal-perfusion is the most devastating condition for surgical treatments. Pericardial hematoma whose CT level is 35 or greater, occurs in myocardial infarction, aortic dissection and medicine.
【References】
1.White, A, et al. "Acute aortic emergencies – part 2: aortic dissections". Advanced Emergency Nursing Journal. 2013; 35: 28–52.
2.Isselbacher E.M.. et al. "Cardiac Tamponade Complicating Proximal Aortic Dissection. Is Pericardiocentesis Harmful?". Circulation. 1994; 90 : 2375–78.
3.Bonser RS et al. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol. 2011;58: 2455-2474
4.Paolo Berretta, et al. Patients presenting with type A acute aortic dissection (TAAD) complicated by malperfusion syndromes represent one of the highest surgical risk cohorts for cardiovascular surgeons. In the setting of aortic dissection, end-organ ischemia. 2018;31:65
5.Pachini D, et al. Acute type A aortic dissection: significance of multiorgan malperfusion. European Journal of Cardio-Thoracic Surgery, 2013;43: 820–826
6.Orihashi K . "Mesenteric ischemia in acute aortic dissection". Surg. Today. 2016; 46 : 509–16.
7.Kamman AV, et al. "Visceral Malperfusion in Aortic Dissection: The Michigan Experience". Semin. Thorac. Cardiovasc. Surg. 2017; 29 : 173–78.
2021.8.20