Management of Idiopathic Infrarenal Aortic Dissection Presenting as Acute Limb Ischemia in a Young Female: A Case Report.
Presenter
Darimireddi Siva KUMAR Kumar, MD, DM, CARDIOLOGIST, FSCAI, Star Pinnacle Heart Centre, Visakhapatnam, Andhra Pradesh, India
Darimireddi Siva KUMAR Kumar, MD, DM, CARDIOLOGIST, FSCAI1, Sudhir Chandra Sinha, M.D, DM CARDIOLOGIST2, Tupakula Suresh, MD, DM cardiologist3 and Naidu Sujatha, MD, Radiologist3, (1)Star Pinnacle Heart Centre, Visakhapatnam, Andhra Pradesh, India, (2)Star Pinnacle Heart Centre, Visakhapatnam, AP, India, (3)STAR PINNACLE HEART CENTRE, visakhapatnam, AP, India
Title:
Management of Idiopathic Infrarenal Aortic Dissection Presenting as Acute Limb Ischemia in a Young Female: A Case Report.
Introduction:
Isolated abdominal aortic dissection (IAAD) is a rare condition representing 1.3% of all dissections, usually limited to the infrarenal aorta. Most patients are male, with a median age of 60 years, and with concomitant high blood pressure. IAADs are generally asymptomatic, may present as abdominal or back pain, while claudication and lower limb ischemia are rare. We describe a rare case of idiopathic infrarenal aortic dissection with occlusion of aorta presenting as acute limb ischemia in a young female.
Clinical Case:
An 18-year old female presented with sudden severe pain in lower abdomen and both lower extremities of 12 hour duration. There were no morphological features suggestive of Marfan or Ehlers-Danlos syndrome. Emergency CT angiogram revealed flow limiting infrarenal aortic dissection extending up to aortic bifurcation with a large thrombus in false lumen. Catheter angiogram revealed almost total occlusion of infrarenal aorta. Decision for emergency revascularization was taken to salvage the limb. Initially low pressure balloon inflation and thrombosuction from true lumen attempted but there was no improvement in flow. Consequently stented with self-expanding Protégé GPS stent (eV3 Plymouth, MN, 55442) 14x60 mmm. This lead to equalization of pressure gradient across the lesion with very good distal flow. Pain and paraesthesia resolved. However, there was residual dissection flap going towards right common iliac artery. A second stent - 14x40 mm Bard E - Luminexx (Angiomed GMBH & Co. Germany) was deployed. There was complete restoration blood flow and salvage of both lower extremities without any sequelae. Aspirin 75mg and clopidogrel 75mg were used post-procedure. CT angiogram repeated after 1 month showed complete closure of false lumen with normal blood flow to both extremities.
Discussion:
IAAD is a rare entity usually involving infrarenal aorta. According to the meta-analysis published by Ilias A. Dodos et al (208 patients with AAD), majority were spontaneous dissections (87.5%) followed by traumatic (6.25%) and iatrogenic (6.25%). Mean age of presentation was 62.2yrs and hypertension was commonest risk factor. Concurrent aortic aneurysm was most often associated with spontaneous dissections (27%). Endovascular repair was preferred over open surgery (45% vs 26%) with low mortality (2% vs 5%) and lower complication rates. Our patient was a young female without any risk factors or connective tissue disorders, who presented with a spontaneous IAAD with acute limb ischemia without any concurrent aortic aneurysm. She was managed effectively by endovascular approach. To the best of our knowledge, an infrarenal aortic dissection at such a young age has not been described previously.