CASE STUDY
A 32-year-old Han Chinese male was sent into the emergency department of the Traditional Chinese medicine hospital of Guangdong Province because of acute substernal chest pain for 7 hours. Past medical history is negative for hypertension and cardiovascular disease, and his family medical history has no record of cardiovascular or aneurysmal disease. He denies smoking or excessive drinking history. When the patient firstly came to the emergency department, his blood pressure came to 261/142 mmHg and with sinus tachycardia at a heart rate of 121 beats per minute. Computed tomography angiography (CTA) demonstrated Stanford A aortic dissection, accumulative three branches of the aortic arch, superior mesenteric artery, and celiac trunk artery; The left renal artery and the inferior mesenteric artery originates from the false lumen, while the right renal artery originates from the true lumen. (Fig. 1). He was transferred to the Cardiovascular department of the First Affiliated Hospital of Jinan University, where the patient was performed urgent surgery. Before the preoperative examination was accomplished the patient was continuously intravenous infusing of Nycomed and Esmolol for anti-hypertensive therapy (goal systolic blood pressure was less than 120 mmHg,and heart rate less than 80 beats per minute) to prevent worsening dissection and aortic dissection rupture. Bedside transthoracic echocardiography revealing ascending aortic dissection, severe aortic regurgitation. The level of hypersensitive troponin is within normal limits. After finishing all the necessary preoperative examination, urgent surgery was performed. The patient underwent hybrid aortic repair surgery, including Bentall procedure, total arch replacement and descending aortic stent implantation. The patient was subsequently discharged 12 days after the surgery without complications, on an oral medication regimen of warfarin (4.5 mg daily), bisoprolol (5 mg daily), amlodipine (5 mg daily), and spironolactone (20mg daily). He presented to his 3-month follow-up clinic appointments with adequate blood pressure control equal bilaterally of upper limbs at about 122/80 mmHg, with no evidence of postoperative complications. CTA showed postoperative aortic valve replacement; the ascending aorta, aortic arch and part of the descending aorta were changed after stent implantation. A little contrast agent entered into the false lumen of the thoracic aortic stent. The tear of the endangium involved the thoracic aorta to the right common iliac artery, innominate artery and left internal carotid artery. The celiac trunk, superior mesenteric artery and right renal artery opened into the false lumen. The left renal artery opens into the true lumen; Mural thrombosis in the lower thoracic aorta false lumen. Laboratory results demonstrated normal complete blood routine tests and blood biochemical tests. The prothrombin time (PT) was 18.1 sec, and international normalized ratio (INR) was 1.48. The decision was made continue to take warfarin, bisoprolol and amlodipine.