Managing Severe Type B Aortic Dissection Complications

Introduction

Recurrent aortic dissection (AD) presents significant challenges in both medical and surgical management due to its high risk of severe complications and mortality. Type B AD, in particular, requires careful hemodynamic control and procedural interventions to prevent life-threatening sequelae. This case highlights the complexity of managing a patient with severe Type B AD, recurrent dissections, and multiple post-procedural complications.

Methods

A 49-year-old woman with uncontrolled hypertension, hyperlipidemia, and atrial fibrillation presented with sudden onset of chest pain radiating to the back and shoulders. Computed tomography angiography (CTA) revealed Stanford Type B AD with an intramural hematoma extending from the descending thoracic aorta to the aortic bifurcation. Initial management included thoracic endovascular aortic repair (TEVAR). However, she subsequently developed severe complications, including an aorto-esophageal fistula, mediastinitis, new pseudoaneurysms, and a second AD distal to the previous repair. A multidisciplinary approach was employed to manage her condition, incorporating anti-impulse therapy, multiple endovascular and open surgical interventions, and critical care support.

Results

Despite extensive medical and surgical efforts—including staged open repair, visceral debranching, and extracorporeal membrane oxygenation (ECMO) initiation—the patient experienced progressive deterioration. Persistent false lumen perfusion, refractory hemodynamic instability, and multi-organ failure ultimately led to cardiac arrest and death.

Conclusion

This case underscores the high-risk nature of recurrent Type B AD and the limitations of current treatment strategies. The need for multiple procedures highlights the challenges in achieving long-term stability. A multidisciplinary approach is essential, but further research into optimal management strategies and novel therapeutic options is needed to improve outcomes in such complex cases.