A 72-year-old woman was admitted to a community hospital with back pain radiating into the chest. On admittance, her blood pressure was 220/110 mmHg, and the ECG was remarkable for a 2 mm ST-elevation in leads V1 to V3. The patient was thought to have unstable coronary disease and treated with nitroglycerine and low molecular weight heparin (LMWH). After initiation of this treatment, the patient became hypotensive with loss of sensibility and motion in her legs and with no palpable pulses in her groins. A CT scan was obtained (Figure 9.2). The CT scan and patient was transferred to the IRAD center and the patient was brought directly to the OR. A strategy of direct surgery was chosen with the intention to relieve the compromised circulation in the descending aorta and treat the life-threatening affection of the ascending aorta.

At the initiation of anesthesia, the patient became abruptly in deep shock with no arterial pressure measurable. She was given heparin directly, her femoral vessels cannulated, and her chest opened. A large accumulation of blood was found in the right pleural cavity. Extracorporeal circulation was initiated, and her blood volume replenished. On surgery, both the left and non-coronary aortic leaflets were found to be destroyed, and the aortic root was replaced with a Medtronic Freestyle 23 mm graft. The ascending aorta and hemiarch was replaced by a 24 mm Vascutec Gelweave graft. The patient was transferred to the ICU in stable condition.

The following day, the sedation was stopped to wake the patient for extu-bation. However, the patient did not regain consciousness and died on day 2 after surgery. An autopsy revealed a large infarct in her right hemisphere and a dissection of the brachiocephalic trunk extending into the right carotid artery.

Figure 9.2. An acute Stanford type A dissection in a 72-year-old woman with loss of sensibility in her legs and no pulses in the femoral arteries. Note the relatively large false lumen in the ascending aorta and an almost compressed true lumen in the descending aorta.

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