This patient illustrates several problems when treating patients with acute aortic dissections. Her rupture illustrates a narrow-escape situation and thus the demand for expeditious treatment of these patients. The patients who are late for treatment and thus a large part of patients in tertiary referral centers represent patients with a natural selection toward good-risk cases as many of the most stabile patients will be operated late. The most dramatic clinical presentation in this patient was the malperfusion of her lower body. However, by looking at her CT, the very fragile and large ascending aorta is obvious. The route of rupture was from the posterior part of the arch along the intercostals space to the right pleural cavity. Finally, there was no indication of a defect in the brachiocephalic trunk leading to the lethal dissection of the precerebral vessels when looking into the arch vessels during surgery. Thus, despite a technical successful repair in a dramatically instable patient, the patient succumbed to a not-detected malperfusion of her brain.

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