UNUSUAL PRESENTATION OF AORTIC DISSECTION WITH RIGHT CALF PAIN

Abstract

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: The incidence rate of acute type A aortic dissection is between 2.1 and 16.3 per 100,000 persons per year. Over 90% of patients with acute aortic dissection present with chest or back pain. In the case of an acute dissection, mortality can be almost 50% within the first 48 hours of symptom onset, 21 to 49% of the patients with aortic dissection die before reaching the hospital. Therefore, prompt diagnosis and treatment is imperative for survival. Aortic dissection can be easily missed in the settings of atypical presentation. We are presenting a case of a 48-year-old male who presented with right calf pain as a symptom of acute aortic dissection. CASE PRESENTATION: The patient is a 48 year old male with no known medical history presented with chief complain of right calf pain. He woke up from his sleep due to severe throbbing pain in his right calf that radiated to the calf with associated paresthesia. He denied recent trauma, prolonged period of immobilization, recent travel, known history of Baker's cyst, insect bites or exertion. Upon further questioning, the patient did report chronic back pain. Vitally, his blood pressure was elevated at 216/126 with no significant difference between both arms, no tachycardic, and not hypoxic. Clinically, his right lower calf is swollen with tortuous vein, not tense. Distal pulses are palpable with a sensory deficit at the dorsum of the right foot. Laboratory studies were only significant of a D-dimer of 32,279. Due to the elevated D-dimer, CTA chest and abdominal CT Aorta/Iliofemoral angiography was obtained that revealed an acute Stanford type A dissection of the thoracoabdominal aorta, large fusiform dissecting aneurysm of the distal abdominal aorta extending into bilateral common iliac arteries with absent distal runoff enhancement to the right foot, indicative of critical limb ischemia. An esmolol drip was quickly started and transferred to high-level care facility for an emergent surgical procedure. DISCUSSION: Our patient presented with an acute right leg pain that prompted us to get a D-dimer to further evaluate for an acute deep venous thrombosis. An elevated D-dimer has been found to have 96.7% sensitivity for aortic dissection, the significantly elevated d-dimer levels prompted an emergent CTA of the chest and abdomen for evaluation of dissection. This case was not considered "text book," since patient did not complain of the typical "tearing" chest pain radiating to the back to be concerned aortic dissection. CONCLUSIONS: Aortic dissection is a life-threatening disease, immediate evaluation can save a patient's life. Since many of these cases are often missed due to atypical presentation, it is imperative to develop awareness regarding the various ways an acute aortic dissection can disguise itself as. This case elucidates the importance of critical limb ischemia and a significantly elevated D-dimer due to an acute aortic dissection. REFERENCE #1: Inga H. Melvinsdottir, Sigrun H. Lund, Bjarni A. Agnarsson, Kristinn Sigvaldason, Tomas Gudbjartsson, Arnar Geirsson, The incidence and mortality of acute thoracic aortic dissection: results from a whole nation study, European Journal of Cardio-Thoracic Surgery, Volume 50, Issue 6, December 2016, Pages 1111–1117, https://doi.org/10.1093/ejcts/ezw235 REFERENCE #2: Wundram, M., Falk, V., Eulert-Grehn, JJ. et al. Incidence of acute type A aortic dissection in emergency departments. Sci Rep 10, 7434 (2020). https://doi.org/10.1038/s41598-020-64299-4 DISCLOSURES: No relevant relationships by Mary Dickow, source=Web Response No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Verisha Khanam, source=Web Response No relevant relationships by Sarwan Kumar, source=Web Response