Through the gap: a case series on managing Type B aortic dissection with multiple lumens and tears.

Aortic dissections are classified as Stanford Type A and B based on site of intimal dissection. Management of Type B dissections is guided by risk stratification. Complicated and high-risk Type B aortic dissections are managed either using endovascular or open surgical repair. Uncomplicated Type B dissections are managed medically. The role of the patency of the false lumen and the presence of reentry tears in the dissecting membrane are still contested. Here, we describe two cases of descending aortic dissections with varying anatomical features in the setting of cocaine use and uncontrolled hypertension. The first case uniquely had a triple lumen dissection with two true lumens, while the second case had two distal tears. Both patients initially had signs of reduced end organ perfusion that resolved with control of comorbid conditions. After multidisciplinary discussions, the decision was made to continue with anti-impulse treatment. Due to the radiological and biochemical absence of evidence of end organ injury even while visceral organs were supplied by the false lumen, our multidisciplinary team preferred conservative management with anti-impulse therapy. This serves as a demonstration of individualized management of Type B aortic dissection in patients with multiple comorbidities using carefully analyzed radiographic and biochemical evidence.