Complex thoracic aortic dissection.

A 50-year-old man presented with sudden onset abdominal pain and non-productive cough. Past medical history was significant for hypertension, treated with hydrochlorothiazide, azilsartan and a beta-blocker. Cardiovascular exam was notable for soft diastolic murmur in right second intercostal space and an abdominal bruit in umbilical region. A chest radiograph revealed a left mediastinal mass (Panel A, Arrowhead). Contrast enhanced computed tomography (CT) of the chest and abdomen revealed a Type 1A, complex thoracic aortic dissection originating at the aortic root (Panel B, four lumens: True lumen [1], acute dissection [2], Sub acute dissection [3] and chronic dissection [4] respectively). The dissection extended down to the mid iliac arteries bilaterally (Image not shown). The patient was transferred to tertiary care center and underwent an aortic root replacement.

CT is the most utilized imaging modality for the diagnosis of aortic dissection.1 The advantages of CT are ready and widespread availability in the emergency department setting, rapid image acquisition, minimal patient discomfort, and sensitivity and specificity approaching 100% with multidetector CT.2 A negative CT may also identify alternative causes for the patient’s clinical presentation. Limitations of CT include false positives from motion artifact in non-electrocardiogram gated scans, false negatives from poor contrast opacification due to cardiac failure or thrombosed false lumen, and identification of intimal flap in only 70% of cases.3,4