An Atypical Case of Silent Aortic Dissection in a Peritoneal Dialysis Patient: A Case Report and Review of Literature

Abstract

Patient: Male, 55Final Diagnosis: Type-A aortic dissectionSymptoms: Exertional dyspnea • orthopneaMedication: —Clinical Procedure: Emergent surgical repair with mesh implantSpecialty: CardiologyObjective:Unusual clinical courseBackground:Aortic dissection presents with acute chest or back pain and is associated with high mortality. We present a case of aortic dissection with an atypical presentation in a peritoneal dialysis patient, and the challenges met with peritoneal dialysis.Case Report:A 53-year-old African American male presented with progressively worsening exertional dyspnea and orthopnea for 3 days without any history of chest pain. His chest x-ray showed mild pulmonary edema. He was admitted with a diagnosis of heart failure. Bedside echocardiogram revealed severe aortic regurgitation and concern for possible aortic dissection. Computed tomography of chest with contrast showed Stanford type-A aortic dissection extending from the aortic valve to the level of the left subclavian artery. Emergent surgery was performed. Postoperatively, the patient was managed in surgical and trauma intensive care unit to keep the blood pressure in the desired range. Initially, he was started on continuous veno-venous hemodialysis and later on transitioned to intermittent hemodialysis. He was switched back to peritoneal dialysis after 6 weeks of surgery.Conclusions:Atypical presentation of a silent aortic dissection without chest pain in the setting of renal failure and other comorbidities emphasizes that dialysis patients are different from the general population. Sometimes the management needs to be modified from the conventional ways to achieve the high level of success.

The usefulness of point-of-care ultrasound in the atypical presentation of aortic dissection: a case series and brief review of literature

“…19 The importance of the rapid and certain diagnosis of aortic dissection is even more true, especially when considering the differential diagnosis with acute coronary syndromes, whose therapy is potentially harmful. 4,20 Literature data support the use of computed tomography for diagnosis in cases showing an indicative or suspicious clinic; 13 however cases with atypical presentation (Table 2 [21][22][23][24][25][26][27][28][29][30][31] ) escape the usual diagnostic algorithms, and the suspicion is formulated only after multiple imaging studies are performed, with considerable delay.…”

Aortic Dissection: An Easily Missed Diagnosis when Pain Doesn’t Hold the Stage

“…About 6% of patients with type A AD do not complain of pain [4]. Some of these present with neurological symptoms or heart failure [5]. Given their rarity, neurological presentations of AD can often be missed at initial clinical examination, a fact that is highlighted in the present paper, in which we summarized the cases of 2 patients with acute type A AD who presented with transient and painless neurological manifestations, all of which were caused by arterial obstruction.…”

Autologous arteriovenous fistula failed due to spontaneous axillary artery dissection in a female hemodialysis patient

“…The pathophysiology of SAAD in HD patients depends on several factors leading to arterial wall weakening. 3 These patients often have an intrinsic weakness in the artery wall that leads to remodeling, resulting in hypertrophy, stiffness, diffuse dilation, and aneurysm formation which contributes to SAAD. 3 Ultrasound can provide prompt screening and essential therapeutic monitoring of arterial dissection.…”

“…3 These patients often have an intrinsic weakness in the artery wall that leads to remodeling, resulting in hypertrophy, stiffness, diffuse dilation, and aneurysm formation which contributes to SAAD. 3 Ultrasound can provide prompt screening and essential therapeutic monitoring of arterial dissection. 4 The original images of MRI and CTA can identify the true cavity, false cavity, and the damaged inner diaphragm of the dissection, which have greater diagnostic value when the dissection is suspected clinically.…”