WHEN AN EVIL NEVER COMES ALONE! - REPORT OF A CASE OF CONCOMITANT AORTIC ANEURYSM AND DISSECTION

Abstract

Introduction: Aortic dissection (AD) is a disease of the medial layer of the vessel, where a false lumen is created. Among the main risk factors, the following stand out: male gender; atherosclerosis; hypertension; smoking. 1 Abdominal aortic aneurysms (AAA) are defined as having a diameter greater than 30 mm and are located almost exclusively in the infra-renal region.4 They are more common in men over 60 years of age. The main risk factors are also: hypertension; smoking and atherosclerosis.4 The case presented below compiles these two pathologies and explains the difficulty of their diagnosis, in an environment with limited physical resources.

Case description: Male, 56 years old, hypertensive and an active smoker. He was admitted to the permanent care service with severe knife-like abdominal pain radiating to the right flank with 2 days evolution, associated with nausea and vomiting. On objective examination, he presented an Arterial Pressor: 140 / 95mmHg; Heart Rate: 101 bpm; the abdomen “in plank” and a pulsating abdominal mass was palpable. In the analytical study: normocytic normochromic anemia with increased inflammatory parameters. He was emergently transported to the referral hospital, where he underwent an abdominal and pelvis CTA that revealed: “ Stanford type B aortic dissection, starting in the arch and up to the iliac bifurcation. The dissection is associated with a large aneurysm (8.7 cm), just below the origin of both main renal arteries “. He was then transported to a hospital in mainland Portugal, where he underwent surgery.

Conclusion: When we come across a male patient, over 50 years old; an active smoker with hypertension and dyslipidemia, it is important to sound the vascular disease alert! The patient presented with signs and symptoms for which we must always be aware and suspect an aortic aneurysm: abdomen with signs of peritoneal irritation, pulsatile mass, in a smoker and with uncontrolled hypertension. Despite being a difficult diagnosis, these patients need emergent intervention, being crucial given their suspicion, the transfer to a hospital. Although the AD diagnosis was accidental, the authors emphasize that dyslipidemia, hypertension and smoking are risk factors for AD and that, if not diagnosed and treated in a timely manner, can result in death. The authors would like to emphasize the importance of controlling CVRF and that is recommended AAA screening with echography2 for all men between 65 and 75 years of age, with a history of smoking. Only this way is possible to prevent emergent complications, which in situations of insularity, are even more difficult to manage. Despite the difficulties that doctors have in carrying out urgent care services in a place with few imaging resources it is crucial to have a good cooperation and communication with reference hospitals, so that these patients do not remain in a local health unit with qualified healthcare professionals but with limited physical resources.