Journal 1pages FINAL 34- - National Board Of Examination

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Correspondence19Case ReportMr. Y.N. Das, 55 yr. oldhypertensive, smoker, malepresented with complains ofbreathlessness class III andorthopnoea for last threemonths. He was keeping well,when about three monthsback he had severeexcruciating pain in chest andin the back in the interscapularregion and he reported to alocal hospital where he wasdiagnosed and treated as acutecoronary syndrome on thebasis of symptoms and ST-Tchanges in the ECG.Gradually his pain lessenedand was discharged onantianginals. However, hecontinued to have poorlycontrolled blood pressure andsubsequently developedgradually progressivebreathlessness and orthopnoea.Examination revealed a pulse of 100/mt regular in both upper limbs.Femoral pulses in both lowerlimbs were feeble andpulsations in popliteal, dorsalispaedis and posterior tibialvessels were barely palpable.However, there was noevidence of limb ischaemia.His blood pressure was foundto be 220/110 mm of Hg.There were bilateral fine creptsin chest and S 4gallop. ECGshowed LVH and ST-Tchanges consistent with strainpattern. Chest X-Ray revealedTrue Lumena CTR of >50%. TTE showed mildconcentric LVH with a normal LVfunction and no regional wall motionabnormality. Based on history, pulseFigure 1. CT Angiography showingtrue and false lumen with intimal flapdeficits, severe hypertension, and absenceof evidence of coronary artery disease,dissection of aorta was suspected andIntimal FlapFigure 2. CT Angiography- digitalreconstruction showing true and false lumencontrast enhanced CT scan was carriedout which revealed dissection of aortabeginning from below the origin of leftsubclavian artery and confined to thoracicaorta with intimal flap blowinginto the true lumen andcausing its substantialnarrowing. A diagnosis ofdistal chronic dissection ofaorta; Type III DeBakey wasentertained and in view ofthreatened lower limbperfusion he was referred forsurgical management afterappropriate medicalmanagement.DiscussionPain is present in 96% ofpatients with dissection ofaorta and an interscapularlocation of pain is consistentwith involvement ofdescending thoracic aorta.Pulse deficits are typically associated withaortic dissection and should be activelysought in suspected cases.Differentiation from acutecoronary syndrome orTrueLumenFalseLumenassociated underlying aorticdissection, especially inInferior Infarcts is vitallyimportant; otherwise theconsequences of thrombolysismay be catastrophic. Howeverit must be recognized that thediagnosis of aortic dissectioncannot be made on the basisof clinical findings alone.Contrast enhanced CT scan/Spiral CT is currently the goldstandard for the diagnosis.Journal of Postgraduate Medical Education, Training & ResearchVol. I, No. I & II77
TEE has comparable sensitivity andspecificity and has advantage of easybedside availability in unstable patients.A chronic dissection can be managedmedically unless there is evidence of vitalorgan or limb ischaemia. Endovascularstenting is a growing viable option.Long-term medical therapy to controlblood pressure and reduce dP/dTdetermines outcome in late follow up.S.K. Mishra & A.K. ThakurHeart Hospital, PatnaReferences1. Spittell PC, Spittell JA Jr. Joyce JWet al.Clinical features and differentialdiagnosis of aortic dissection; MayoClinic Proceedings, 1993 68:642.2. Kamp TJ et al, myocardial infarction,aortic dissection, and thrombolytictherapy; Am Heart J 1994 128:1234.3. Moore etal. Choice of CT, TEE,MRI and aortography in acute aorticdissection; IRAD. Am J Cardiol 200289:1235.4. Dake MD et al, Endovascular stentgraft placement for the treatment ofacute aortic dissection. N Eng J Med,1999 340:1539.5. Januzzi JL et al: Refractory systemichypertension following Type B aorticdissection. Am J Cardiol 2001 88:686.Figure 3. CT Angiography- Spiral(Hellical) reconstruction showing a virtual cutoff Aorta due to distended bulging intimal flap into the lumen.78Journal of Postgraduate Medical Education, Training & ResearchVol. I, No. I & II
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Journal 1pages FINAL 34- - National Board Of Examination

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