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Wave 2: Module 3: Aortic Week 4 – Case 1
- May 19, 2025
- Posted by: admin
- Category: Uncategorized
48 years old gentleman presented to emergency department with sudden chest and interscapular pain,
He has only history of DM,
No cardiac history
Hb 13 gm/dl
Emergency department called you and cardiology team to review the patient
CTA images included
What would your assessment approach (history taking , clinical examination, investigations and monitoring approach)
What should be the management plan and discussion with other teams
What would be your discussion with patient and family entitles
What is your inpatient stay goals and plan and discharge plan
3 days later during his admission on CCU under labetalol infusion, he developed right leg numbness and pain, and his kidney functions dropped by 20% and his lactate increased to 2.3
What would be the investigation of choice
What would be your management plan
What would be the discussion with the patient and family entitles
Please support your answers with guidelines/evidence
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my approach regarding history chest/interscapular pain; ask for neuro deficits, abdominal/flank pain, limb symptoms.
Exam: bilateral BPs/pulses, new early diastolic murmur (AR), focal neurology, cold/painful limb, signs of tamponade
and prepare for urgent CTA
Council the patient for diagnosis of dissection and its morbidities and mortalities
after the CTA if it is type A then urgent intervention is a must
if it is type B :
uncomplicated then medical ttt and follow up
if it is complicated prepare for TEVAR
in hospital close monitoring of the vital signs and labetelol infusion, with serial lab investigations including lactate and creatinine
The event after 3 days indicates malperfusion syndrome of complicated type B dissection
1. urgent CTA
2. management is urgent TEVAR
3. discuss the need for urgent intervention with possible of limb or renal failure and expected mortality
A1
Pain analysis according to socratis
I will examine pt Vitals BP Hr sat Rr temp and peripheral pulsation
I will order ECG d dimer CT ANGIO
Monitoring Vitals and peripheral pulsation
…
A2
Discuse with internal medicine to control DM and HTN, anaesthetist if we need intervention and cardiologist heart condition
Approach of mang
Conservative
Control BP systolic 100 – 120 mmhg
Giving iv labetelol
Pain control
.
With relative I will Discuse pt condition that
He had aortic dissection un complicated type b for conservative tt and speak about complication
Limb ischemia may be organ failure
.
Follow up image 3 months
….
A3
Repeat CTA or MRA
And role out progression of aortic dissection and there is no arterial oculsion
Revised management plan
Adjustment of libetolol
Iv fluids support
Assessmet of limb perfusion and heparinzation
Consider fem fem bypass
Defenetive mange
Carotid subclavian bypass followed by TEVAR with Lt subclavian covarge
And renal artery stent and iliac
……
A4
Update pt with his condition and complication
A1. Assessment Approach
A2. Initial Management Plan
A3. Discussion with Patient & Family
A4. Inpatient Goals & Discharge Plan
A5. Investigation of Choice
A6. Revised Management Plan
A7. Updated Discussion with Patient & Family
Thanks
Please try to have your own concise approach showing your methodical management rather than getting an AI input into your answer
A1 assessment approach
1-History Taking
• Character of pain: Sudden, tearing, radiating to back suggests aortic dissection
• Risk factors: HTN (assumed), DM, no cardiac history
• Associated symptoms: Neurological (leg numbness), abdominal pain (possible ischemia), syncope
2-Investigations
• Vital signs monitoring (BP in both arms, HR, SpO2)
• ECG – rule out MI
• Labs: D-dimer, renal function, lactate, CBC, troponin
• CTA chest-abdomen-pelvis – already done; confirms/disproves aortic dissection
3-Clinical Examination
• Vascular exam: pulses in all limbs
• Neurological assessment
• Cardiopulmonary auscultation
⸻
A2 Initial Management Plan
1- Discussion for vascular team with
• Cardiology
• Cardiothoracic surgery
• Anesthesiology/ICU
2-ESVS recommended Medical Treatment for uncomplicated type B AD
• Blood pressure control (target SBP 100–120 mmHg)
• IV labetalol or esmolol
• Pain control: IV opioids (reduces sympathetic tone)
⸻
A3 Discussion With Patient & Family
• Diagnosis: acute aortic dissection
• Nature: Life-threatening, needs close monitoring and possibly surgery
• Plan: Close monitoring, medical stabilization, surgery if needed
• Risk of complications: limb ischemia, organ failure
⸻
A4 Inpatient Goals & Discharge Plan
• Monitor for complications: ischemia, organ dysfunction
• If Type B confirmed to be uncomplicated → medical management + follow-up imaging
• Discharge plan:
⸻
A5 New Event Investigation of Choice
• Repeat CTA (aorta & lower limbs) or MR Angiography
• Rule out: progression of dissection, limb ischemia, aortic branch vessel involvement
⸻
A6 Revised Management Plan
⸻
A7 Updated Discussion with Patient & Family
• Explain deterioration: signs of ischemia, possible aortic progression
• Risk of losing limb or organ function
• May require emergency vascular intervention
• Prognosis has changed; discuss possible outcomes honestly
Well done, good answer
I would appreciate if you add the guidelines supports every section of your answer please
A1.
History taking of Hypertension , smoking , family history
Examination for blood pressure monitoring to get her with heart rate to exclude shock state
Examination of peripheral pulsations
Laboratory inv. CBC, LFT,KFT, Lactate level
ECG or ECHO. To detect ischemia
Monitoring plan should be in ICU with vigorous control of BL.Pressure with IV beta blockers
A2..
The management plan as long as it is uncomplicated type B TAD is mainly medical
I will discuss that with the family that medical therapy is such condition has better survival rate than intervention
My in patient stay goals is to controle blood pressure to prevent progression of the dissection flap and to achieve pain relief
A3..
Now the patient become symptomatic and developed malperfusion syndrome
My investigation of choice is CTA do detect the level of dissection distally and proximally
My plan now is to stabilize the patient and tp prepare for intervention
I will discuss with the patient and the family the high mortality rate of interventional therapy
Weel done, please try to highlight evidence for your decision
What kind of intervention is suggested
َQ1:
history taking about the nature of the pain or previous attack , hypertension ,family history of CT disorders, smoking
examination of the peripheral pulsation any neurological deficit
will do full blood count and kidney function test and ECG and Echo
according to the CTA it is a case of type B AD and needs close monitoring of his blood pressure and control of hypertension with follow up of his urine out put and peripheral pulsations to early detect any signs of complications
Q2:
ESVS guidelines recommends treatment of the uncomplicated type b AD with medical management of his Hypertension with BB and pain control
Q3:
that uncontrolled hypertension was the cause of the pain that happened due to aortic dissection and once it is non complicated with any organ malfunction medical management is the best option for him with control of the blood pressure until the false lumen get clotted
and intervention only will be done if complications happen
Q4:
CTA is the investigation of choice for assessment of the complication and the progression of the dissection
Q5:
urgent TEVAR and after that assessment of the renal artery and lower limb arteries and manage accordingly may need covered stents also in renal or iliac artery
Well done, what could be the possible complications of intervention please
A1:
History regarding medical social family of ct disease and analysis of complaints along with previos trauma
Examination general and local for vital signs limb perfusion abdominal cardiac and neurological
Investigations in the form of labs and images
CBC INR KFT LFT ABG for lactate
TTE TEE CTA or MRA of the whole aorta down to the femoral for the site of pathology perfusion visceral renal and limb size of aorta classification of the disease together with planning for management
Monitoring under bl pr control 100-120 ABG for lactate as a predictor for hypo perfusion p pulsation
Patient counseling for the diagnosis which is a type b AD of the whole DTA and abdominal down to the iliac that needs ITU admission close observation and monitoring with tight bl p control and HR 60-80 BPM via iv b blockers and vasodilator in refractory cases with follow up as far we pass the acute stage then we have to deal with this pathology as staged procedure first by carotid subclavian bypass then TEVAR with LSA covering regarding the ESVS guidelines that TEVAR is the best management for complicated type b AD regarding the mortality stroke and paraplegia
A2:
It seema that the ptn had ALI. and AKI due to thrombosis of the rt iliac a dissection
As long as the kidney functions detriorated so arterial duplex would be the best choice to evaluate the perfusion of the limb and correlation with symptoms signs and high lactate
Management plan for this situation are iv heparine fluids with o2 supplement to limid the ischemic insult and prepare the patient for AD endovasculare ttt with fem fem cross over to save the rt limb
Ptn and family should be counseled for the plane of management and complication of limb ischemia that may need dialysis to overcome the AKI
very good , well done