Aortic pseudocoarctation in a patient with chronic aortic dissection

Marco, Daniel N.; Prieto-González, Sergio; Castro Rebollo, Pedro

doi:10.1016/j.medcle.2022.08.015

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Marco, Sergio Prieto-González, Pedro Castro Rebollo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Daniel N." "apellidos" => "Marco" "email" => array:1 [ 0 => "dnmarco@clinic.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Sergio" "apellidos" => "Prieto-González" ] 2 => array:2 [ "nombre" => "Pedro" "apellidos" => "Castro Rebollo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Área de Vigilancia Intensiva, IDIBAPS, Universitat de Barcelona, Servicio Medicina Interna, ICMID, Hospital Clínic Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Seudocoartación aórtica en un paciente con disección aórtica crónica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 877 "Ancho" => 1654 "Tamanyo" => 128685 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Computed tomography angiography of the aorta. (A) Coronal section showing a decrease in the true caliber (filled with contrast medium) at the expense of dilatation of the false lumen. (B) Three-dimensional reconstruction showing the area of elongation (arrow) responsible for the deformation of the prosthetic material." ] ] ] "textoCompleto" => "In this paper we present the case of a patient who was recently admitted to our service with pseudocoarctation of the aorta, an unusual complication of chronic aortic dissection, and highlight the importance of the diagnostic methods used to detect and solve this condition.The patient was a 69-year-old woman with a history of arterial hypertension and an aortic dissection of Stanford<a class="elsevierStyleCrossRef" href="#bib0005">1</a> class A, extending from the ascending aorta down to the root of the renal arteries, two years prior to the current episode. Following an initial intervention, during which a stent was placed within her ascending aorta and aortic arch while maintaining the native valve, the false lumen continued to remain permeable due to the presence of leaks from the implantation site of the left subclavian artery. These leaks were corrected by retrograde embolization and the subsequent placement of additional stents within the descending aorta, down to the root of the renal arteries. As a result, throughout the following two years, a large part of her native aorta was patchily replaced by tubular implants.The patient was admitted to the conventional hospital ward with a clinical picture suggestive of biventricular heart failure refractory to diuretics, in addition to refractory arterial hypertension, a deteriorated kidney function, and anemia (creatinine 3 mg/dl, corresponding to an estimated glomerular filtration rate of 14 ml/min; hemoglobin 71 g/l). On physical examination, she had a palpable and symmetrical pedal pulse, albeit with a very low ankle-brachial index (<0.4). The diagnostic study was completed with an analysis of laboratory parameters allowing for determining the etiology of the patient’s anemia, including the following: ferritin, vitamin B12, and folic acid within the normal range; decreased haptoglobin levels; lactate dehydrogenase (LDH) 361 IU/l; negative Coombs test; reticulocyte count of 2.4% and absence of visible schistocytes, all of which were compatible with intravascular hemolytic anemia. An echocardiogram showed signs of diastolic dysfunction, with a preserved ejection fraction and indirect data of pulmonary hypertension. A computed tomography angiography was also requested, observing aortic elongation at the level of the thoracic descending artery and compression of the prosthetic material by the false lumen, which was causing very significant stenosis of the true lumen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Based on the above findings, the diagnosis was oriented toward a pseudocoarctation of the aorta, in which the intraaortic stenosis was generating a pressure gradient at said level that was causing the patient’s symptoms.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Three distinct areas could be differentiated both anatomically and pathophysiologically in relation to the stenosis. First, the prestenotic area, corresponding to the aortic arch and the supraaortic trunks, which were hyperpressurized, therefore explaining the patient’s refractory arterial hypertension and heart failure secondary to the increased afterload. Second, the area of stenosis affecting the true lumen lined by a stent, at which level an acceleration of the blood flow occurred, consequently resulting in hemolysis of the circulating red blood cells. Third, post-stenotic area (from the thoracic descending aorta downwards) with hypoperfusion, which was responsible for the patient’s kidney failure, hydrosaline retention, and reduced ankle-brachial index.After reaching this diagnosis, an intravascular pneumatic balloon dilatation was carried out. A few days after this procedure, the patient’s congestion and kidney function improved rapidly, she no longer had hemolytic parameters, and her blood pressure had returned to normal levels.Despite the exceptional nature of this form of presentation, aortic dissection commonly cronifies following initial rescue therapy. Significant improvements have been made in the initial care of acute aortic dissection and, therefore, an increasing number of patients survive this acute event. However, it should be remembered that the false lumen often fails to disappear and the artery might remain divided into two lumens that are in a state of constant equilibrium, which could cause irrigation problems in different organs.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> A high degree of suspicion, careful review of the interventions performed, and, above all, good diagnostic methods are crucial in diagnosing complications in this type of patient.Ethical considerationsThis article is based on a description of a real clinical case. Our site’s protocols regarding the use of patient data for informative purposes and the guidelines for the anonymization of identifying data were followed.We were granted the patient’s verbal consent to present this case in sessions and to publish it for teaching or informative purposes relating to her disease. All data that could allow the patient’s identification have been omitted.FundingWe received no funding for this work.Conflicts of interestThe authors of this paper declare no conflicts of interest." 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(A) Coronal section showing a decrease in the true caliber (filled with contrast medium) at the expense of dilatation of the false lumen. (B) Three-dimensional reconstruction showing the area of elongation (arrow) responsible for the deformation of the prosthetic material." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute type A aortic dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.S. Elsayed" 1 => "R.G. Cohen" 2 => "F. Fleischman" 3 => "M.E. Bowdish" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ccl.2017.03.004" "Revista" => array:6 [ "tituloSerie" => "Cardiol Clin" "fecha" => "2017" "volumen" => "35" "paginaInicial" => "331" "paginaFinal" => "345" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28683905" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Commentary: cracking the code for chronic aortic dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.E. Roselli" 1 => "L.G. Svensson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2020.02.115" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2021" "volumen" => "162" "paginaInicial" => "1474" "paginaFinal" => "1475" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32284145" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic rupture due to pseudocoarctation caused by migrated stent graft" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Uğur" 1 => "İ. Alp" 2 => "İ. Selçuk" 3 => "V. Temizkan" 4 => "A.E. Ulucan" 5 => "A.T. Yılmaz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.15511/ejcm.18.00122" "Revista" => array:5 [ "tituloSerie" => "EJCM" "fecha" => "2018" "volumen" => "6" "paginaInicial" => "19" "paginaFinal" => "22" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015900000012/v2_202301310808/S2387020622005484/v2_202301310808/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015900000012/v2_202301310808/S2387020622005484/v2_202301310808/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622005484?idApp=UINPBA00004N"]

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Vol. 159. Issue 12.