Spontaneous isolated abdominal aortic dissection involving the celiac, superior mesenteric, inferior mesenteric, right renal, left iliac, and right superficial femoral arteries

Abstract

A 55-year-old man presented to the emergency department after waking with severe back pain migrating to the abdomen, systolic blood pressure >230 mm Hg, and noncompliance with antihypertensive medications. Computed tomography angiography of the chest and abdomen showed an aortic dissection originating at the diaphragmatic hiatus and extending to the left external iliac and right superficial femoral artery (A and B). The dissection extended into the celiac and superior mesenteric arteries without malperfusion and extended into the inferior mesenteric artery with thrombosis (C). A complex intimal flap extended into the right renal artery, resulting in attenuation of the nephrogram (D). The patient was initially managed with intravenous antihypertensive (esmolol, clevidipine) medication, and the abdominal pain resolved. There was no evidence of bowel or lower extremity ischemia, and urine output was adequate. On hospital day 2, he developed paralysis of the lower extremities with preservation of sensation. He underwent an emergent stent graft (TAG; W. L. Gore & Associates, Flagstaff, Ariz) repair of the entry tear, and symptoms resolved. Two days after surgery, the paralysis returned and renal function decreased. A left renal artery stent (Complete SE; Medtronic, Minneapolis, Minn) was placed with minimal improvement. Fewer than 100 cases of isolated abdominal aortic dissection exist in the literature. Dissections extend distal to the common iliac artery in less than half of the cases and rarely extend into visceral arteries. More than one third of isolated abdominal aortic dissections occur with abdominal aortic aneurysms, 51% to 78% have hypertension, and the majority present with acute aortic symptoms. Presenting symptoms include abdominal pain (47%), back pain (23%), claudication/limb ischemia (17%), and paraplegia (3%); 17% are asymptomatic. Because of the small number of cases, no consensus exists on treatment. Options include open or endovascular repair and medical management. Surgical indications include rupture, visceral or limb ischemia, renal failure, visceral extension, refractory pain, and continued hypertensive crisis. The overall in-hospital mortality is 5%, as is the incidence of lower extremity neurologic symptoms. Some studies suggest that the long-term mortality is higher in patients who are medically managed, leading them to recommend a more aggressive surgical or endovascular approach and to propose that endovascular therapy be used when possible.