{
  "abstract": "Introduction An aortic dissection is a serious condition in which a tear occurs in the inner layer of the body’s main artery (aorta). Blood rushes through the tear, causing the inner and middle layers of the aorta to split (dissect). If the blood goes through the outside aortic wall, aortic dissection is often deadly. It is relatively uncommon. It usually occurs in men in their 60s and 70s. It’s important to recognise aortic dissection as soon as possible as it can be a fatal condition. Due to the heterogeneity of clinical features of AAD, misdiagnosis is common, where it is most often confused with ACS. 1 Aortic endograft infection (AEI) has been reported to occur in 0.6% of cases after endovascular aneurysm repair (EVAR).2 This case presents a complex clinical scenario of a 56-year-old man with hypertension who initially presented with symptoms of acute coronary syndrome (ACS) but was later found to have aortic dissection, leading to a series of critical interventions and complications.Case Presentation The patient presented with chest pain radiating to the back and shortness of breath. His blood pressure was severely elevated at 220/96 mmHg, and he had a significant history of hypertension but was non-compliant with medications. Initial workup suggested Non-ST-Elevation Myocardial Infarction (NSTEMI), based on elevated troponin levels (27.9 to 143.4) and ECG changes (T wave inversions in leads I, aVL, V5, V6). He was treated accordingly with aspirin, clopidogrel and morphine, and percutaneous coronary intervention (PCI) was planned. A routine pre-PCI echocardiogram revealed a dilated and effaced ascending aortic root with type A dissection flap in ascending and descending aorta. Moderate aortic regurgitation, impaired LV function (EF 40–45%), and small-to-moderate pericardial effusion were also noted. Further Imaging (CT Aortogram) confirmed an aortic dissection flap extending from the left subclavian artery to the aortic bifurcation, with the inferior mesenteric and renal arteries arising from the false lumen. Worsening renal function raised concerns about malperfusion.Given the aortic dissection, management for ACS was stopped, and strict blood pressure control was initiated with a target of less than 120/60 using labetalol and heart rate of less than 60. After discussions, the dissection was classified as Type B with complications like aortic regurgitation and renal artery involvement. The patient underwent an urgent Frozen Elephant trunk procedure with aortic valve replacement due to dissection and aortic root pathology.He ended up in ICU following the development of hypoactive delirium and neurological deficits like tremors, dysphasia, dysarthria and weakness, which led to an MRI showing multiple acute infarcts. He received 300mg of aspirin for 14 days and 75mg of Clopidogrel thereafter. He also developed a chest infection confirmed on CT thorax, abdomen and pelvis with bilateral pleural effusions, for which he had multiple broad-spectrum antibiotics and got discharged.He was re-presented with sepsis due to Enterococcus faecalis raising suspicion of endocarditis. Blood cultures were positive, but multiple imaging modalities (TTE, TOE, CT) failed to show vegetation or a clear source of infection. A Cardiac PET scan, then, confirmed an infection of the thoracic aortic stent graft. The patient was managed conservatively with teicoplanin and was discharged on outpatient parenteral antimicrobial therapy (OPAT) for 6 weeks, followed by long-term oral antibiotics for 3–6 months. Surgery was deemed too high-risk.Discussion The initially misdiagnosed NSTEMI highlights the challenge of differentiating aortic dissection from acute coronary syndromes, especially with overlapping symptoms like chest pain and elevated troponins. The involvement of renal arteries in the false lumen resulted in acute kidney injury, adding complexity to the dissection management. The need for urgent surgery due to aortic valve involvement was life-saving, but neurologic and infectious sequelae complicated the postoperative course. The late complication of stent graft infection required a prolonged course of antibiotics. The decision to avoid re-do surgery due to its fatal risks was critical, opting for a conservative, infection-control approach.Abstract 3-001 Figure 1Abstract 3-001 Figure 2Conclusion This case underscores the complexity of managing aortic dissection, especially when compounded by end-organ malperfusion, postoperative complications, and graft infections. The multidisciplinary approach involving cardiology, vascular surgery, neurology, and infectious disease teams was essential for optimizing patient outcomes.References Case Report: Acute aortic dissection: a missed diagnosis - PMC (nih.gov) Aortic Endograft Infection: Diagnosis and Management - PMC (nih.gov)",
  "authors": [
    {
      "affiliations": [
        "Royal Berkshire Hospital, Reading, Berkshire, UK"
      ],
      "name": "Muhammad Zohaib Amjad"
    },
    {
      "affiliations": [
        "Royal Berkshire Hospital, Reading, Berkshire, UK"
      ],
      "name": "Humda Zafar"
    }
  ],
  "title": "3-001 A rare case with atypical management of complicated aortic dissection type B followed by Cerebral Infarct and Graft Infection",
  "uid": "2903416f-215c-5387-8875-55363dbf2284"
}