INTRODUCTION: Aortic dissection is the most common and most lethal catastrophe involving the human aorta. The prognosis of untreated aortic dissection is dismal, with 25 percent mortality within 24 hours and 50 percent within 1 week. Lower extremity ischemia as one of the presenting manifestations of aortic dissection is seen in up to 26 percent of patients , but isolated ischemia of the lower extremity due to aortic dissection is rare and is described in only a few reports. This report describes a case of aortic dissection in which the main feature at presentation was acute right leg ischemia.
CASE PRESENTATION: A 25 year old African American gentleman with no known past medical history presented with vomiting and pain in right thigh for one day. As per patient he attended a party last night where he participated in a group dance for 15 minutes. Two hours later he was engaged in sexual activity, but had to stop because of sudden onset of severe pain in right thigh. Next morning he had three episodes of non-bloody projectile vomiting with red discoloration of urine. No complains of shortness of breath, chest pain, cough, headache, trauma, smoking or drug abuse. On physical examination patient was alert, awake and oriented, lying in bed in moderate distress. Vitals were within normal limits. Chest was clear to auscultation with bilateral vesicular breathing. Both heart sounds were regular with no added sound. Right thigh was tender on medial side. No discoloration or bruising was noticed. Pulses were equal in both limbs. Laboratory data showed severe Rhabdomyolysis (CPK 332674) and acute renal failure. CXR was normal except for prominent aortic knuckle. Initial assessment of Severe Rhabdomyolysis secondary to trauma/ischemia was made. Patient was admitted to medical floor. IV hydration was started with target output of 250 to 300ml/hr. Sodium bicarbonate IV was given to maintain urinary PH > 6.5. Twelve hours later, patient was still complaining of right thigh pain and tightness. Pulses in right lower extremity were feeble on palpation. Labs showed CPK of 683502 with worsening renal and liver functions. Echocardiogram was done to rule out Intra-cardiac thrombus, which revealed dissection of ascending aorta. Patient was immediately transferred to the nearest cardiothoracic centre where a computer tomography scan with intravenous contrast revealed ascending thoracic aorta Stanford Type A dissection, extending distally to external iliac artery. He underwent interposition graft repair of the aortic dissection. Later he was discharged home in a stable condition.
DISCUSSIONS: Incidence of pain free dissection varies between 5-15% and is more common in Marfan syndrome or other connective tissue disorders. Lower extremity symptoms accompanying dissecting hematomas of the aorta are well described but isolated lower extremity ischemia as the presenting syndrome of aortic dissection is rare and frequently misinterpreted so that the diagnosis of aortic dissection is delayed or missed, often with catastrophic results. . An acronym "ILEAD" had been coined standing for ischemia of the lower extremity due to AD . It is a rare presentation the incidence of which in one study was less than 10 out of 1751 cases of AD.
CONCLUSION: 1-Aortic dissection is the most common and life threatening catastrophe affecting aorta, which requires prompt recognition and treatment to avoid dismal outcomes.2-Isolated ischemia of the lower extremity due to aortic dissection is rare and is described in only a few reports. Aortic Dissection should be considered in differential diagnosis of patients presenting with isolated lower limb pain.
DISCLOSURE: Saurabh Parasramka, No Financial Disclosure Information; No Product/Research Disclosure Information