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.