Conservative Management of Chronic Aortic Dissection with Underlying Aortic Aneurysm
A 68-year old female presented to the emergency department complaining of nausea and vomiting which were getting progressively worse over the morning of her admission. She also complained of a central epigastric pain, which she described as sharp, non-stabbing and non-radiating. The pain was rated as 9 out of 10 on the intensity scale and she recalled the pain started shortly after the episodes of vomiting. Episodes of headache, dizziness, lightheadedness and slight blurring of vision were also reported but she denied any syncope, fever or chills. In terms of past medical history, she suffered from hypertension, hyperlipidemia, an abdominal aortic aneurysm and chronic renal insufficiency status post pyleography.\nOn examination on admission to the emergency department, the patient was found to be in hypertensive crisis with the highest blood pressure reaching 206/102 on her left arm and 243/129 on her right arm. On general observation, she was found to be appropriately orientated but in moderate distress with diaphoresis. Clinical observations recorded included a heart rate of 74 beats/min, respiratory rate of 32/min, while pulse oximetry was 97%. Abdominal examination revealed a soft, non-tender, non distended abdomen with normal bowel sounds. No carotid bruits were heard on auscultation and no palpable or pulsating mass was found. The epigastric area was tender but there was no guarding or rebound tenderness. Her cardiovascular examination revealed mild tachycardia, normal heart sounds, no murmurs and no gallop. Her respiratory examination was unremarkable apart from the presence of rales in the lungs. No abnormalities were detected in the peripheral pulses. As a first-line investigation, an echocardiogram was ordered which showed a normal sinus rhythm and non-specific ST-T wave changes. Cardiac enzymes, amylase, lipase and troponins were also ordered and were all within normal limits. Her chest X-ray was also normal showing a normally proportioned heart and no abnormality in the thoracic aorta. There was no pulmonary congestion, infiltrates or pleural effusions. Other baseline investigations included a complete blood count, liver function tests, and urea, electrolytes and creatinine levels.\nBased on the location, nature of the pain and the clinical observations of the patient, a provisional diagnosis of acute aortic aneurysm was made. The first-line management was to control her excessively high blood pressure so as to reduce the risk of any possible complications. She was, therefore, started on an i.v. nitroglycerin drip in the emergency department and later switched to a nicardipine i.v. drip as there was only an initial response to the nitroglycerin. With her pain adequately managed, she was admitted to the cardiac care unit to ensure strict blood pressure control which was appropriately kept under 110/70. Computed tomography (CT) of the chest, abdomen and pelvis was performed and an aortic aneurysm was found at the base of the diaphragm. This was consistent with her history of an aneurysm that in 2006 measured 4.4 cm. Further investigation with an MRI confirmed the presence of an aneurysm still spanning 4.4 cm, but in addition, a chronic aortic dissection in the descending thoracic aorta was also seen. The dissection was located at the level of the celiac artery and measured 5.0 cm. The presence of thrombi and calcifications within the lumen created by the aortic dissection makes the dissection consistent with a chronic presentation versus an acute episode.\nOnce stabilized, the patient was reassessed and it was concluded that her epigastric pain was most likely due to hypertensive emergency with an underlying aortic aneurysm and chronic aortic dissection. Based on the location of the dissection, it was classified as Stanford B, and given the aneurysm was less that 5.5 cm, it was decided that it would be best managed conservatively with strict blood pressure control. The patient was, therefore, started on labetolol. Strict control of the patient’s blood pressure and hyperlipidemia was also the conservative choice in treatment of the coexisting aneurysm. The patient has now been monitored for the last two years.