Late diagnosis of aortic dissection (14 days)

anesthetic challenges – case report

Abstract

Introduction: Acute type A aortic dissection (ATAAD) is a highly lethal cardiovascular emergency, with mortality exceeding 50% within the first 24 hours if untreated. Early diagnosis is critical for prognosis, yet atypical clinical presentations frequently delay both suspicion and confirmation. Case report: An 80-year-old male with a history of systemic arterial hypertension, hypothyroidism, dyslipidemia, chronic hepatitis C, and epilepsy was initially admitted to a regional hospital with nonspecific symptoms of nausea, vomiting, and abdominal pain. During hospitalization, he developed seizures and aspiration, receiving empirical antibiotic therapy. Fourteen days after symptom onset, chest CT angiography revealed an intimal flap in the ascending aorta, consistent with type A dissection, and he was transferred to a referral center. He underwent surgical repair under target-controlled total intravenous anesthesia (TIVA-TCI), with multimodal monitoring and massive transfusion due to associated coagulopathy. Initially, he remained stable, with early extubation and progressive weaning from vasopressors. On postoperative day six, however, he developed septic shock caused by Pseudomonas aeruginosa, followed by progressive multiorgan failure and death. Discussion: The atypical presentation of ATAAD, with gastrointestinal and neurological manifestations, delayed diagnosis. Survival beyond seven days without surgical intervention is uncommon and was likely related to clot formation sealing the false lumen. Anesthetic management required slow, titrated induction, stable maintenance with TIVA-TCI, judicious use of vasopressors, and aggressive correction of coagulopathy, underscoring the complexity of such cases. Despite technically successful surgical repair, the outcome was unfavorable due to late infectious complications, consistent with the high morbidity and mortality reported in elderly patients undergoing prolonged cardiopulmonary bypass. Conclusion: This case highlights the importance of early clinical suspicion in atypical presentations, the pivotal role of the anesthesiologist in hemodynamic and hemostatic management, and the need for individualized strategies to optimize survival in cases of type A aortic dissection with delayed diagnosis.