Repeated Peripheral Embolisms associated with Chronic Aortic Dissection
06 June 2019 (online)
A male patient developed acute type B aortic dissection (AD) extending to the right external iliac artery (EIA) and left common femoral artery at the age of 56 years. Two months after the diagnosis of AD, he developed right renal infarction suggesting embolism, as the right renal artery arose from a false lumen containing a mural thrombus. Seven years later, at the age of 63 years, the patient was readmitted for acute onset of intermittent claudication in the right leg. On admission, arterial pulses distal to the right femoral artery were absent. The right ankle-brachial pressure index (ABI) was 0.66, while the left ABI was 1.06. Computed tomography (CT) confirmed chronic type B AD and revealed a localized occlusion of the right EIA and disappearance of a small protruding thrombus in the false lumen that was found on the previous CT, suggesting a second embolism. Since recovery of antegrade blood flow was insufficient after catheter embolectomy, femorofemoral bypass was performed with resolution of ischemic symptoms. Postoperatively, the ABI recovered to 0.99 in the right and 1.12 in the left, and CT showed a patent bypass graft and restoration of blood flow to the right leg. This case indicates that embolism should be recognized as one of the possible causes of acute organ ischemia in patients with AD, even in patients with chronic AD.
Keywordsaortic dissection - fragmentation of a mural thrombus - ischemic complication - limb ischemia - peripheral vascular embolism - renal embolism - type B aortic dissection.
S.A. was the major contributor in writing and drafting the manuscript. M.A., K.W., T.K., and H.Y. participated on data and figures collection and drafted the manuscript. All authors read and approved the final manuscript.
Ethics Approval and Consent for Publication
The current study was approved by The Institutional Research Ethics Board at St. Mary's Hospital (18-0701). Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
- 1 Cambria RP, Brewster DC, Gertler J. , et al. Vascular complications associated with spontaneous aortic dissection. J Vasc Surg 1988; 7 (02) 199-209
- 2 Arata K, Imagama I, Shigehisa Y. , et al. Aortic fenestration for type B chronic aortic dissection complicated with lower limb malperfusion induced by walking exercise. Ann Vasc Dis 2015; 8 (01) 29-32
- 3 Lévy S, Morales AR, Boucek RJ. Acute thromboembolism associated with dissecting aneurysm of the aorta; two case reports. J Thorac Cardiovasc Surg 1973; 66 (01) 82-86
- 4 Nakahira A, Ogino H, Matsuda H. , et al. Postural change causing leg malperfusion resulting from expansion of a patent false lumen in type B aortic dissection. J Thorac Cardiovasc Surg 2007; 134 (04) 1046-1047
- 5 Gargiulo M, Bianchini Massoni C, Gallitto E. , et al. Lower limb malperfusion in type B aortic dissection: a systematic review. Ann Cardiothorac Surg 2014; 3 (04) 351-367
- 6 DeBakey ME, Lawrie G. Intimal intussusception: unusual complication of dissecting aneurysm. J Vasc Surg 1984; 1 (04) 566-568
- 7 Schraft Jr WC, Lisa JR. Dissecting aneurysm of the aorta with peripheral embolization: a case report. Ann Intern Med 1951; 34 (02) 507-510
- 8 Bernabeu E, Castellá M, Barriuso C, Mulet J. Acute limb ischemia due to embolization of biological glue after repair of type A aortic dissection. Interact Cardiovasc Thorac Surg 2005; 4 (04) 329-331