Material and Methods
We retrospectively evaluated clinical outcome, presentation and surgical technique to understand whether if it was possible an another surgical approach or further diagnostic investigation to uncover a coronary disease. The study was performed in the University Hospital of Bari, Italy and were approved by the Ethical Committee of the hospital. Written informed consent was obtained from the patient. All scientific literature were obtained from medical databases.
A 35-year old man was referred to our unit for evaluation of new onset of type A aortic dissection evidenced at CT scan in a follow up program. The patient was affected by type B acute aortic dissection treated on February 2016 with percutaneous fenestration of the false lumen. The dissection ( De Bakey type III) started from thoracic descending aorta, with the intimal flap within the left subclavian artery and re-entery flap involving the iliac bifurcation. The celiac axis, the superior mesenteric artery with both renal arteries result from the false lumen. Futhermore, the origin of celiac axis and mesenteric artery were obstructed by the intimal flap with signs of incipient abdominal ischemia. These conditions were treated by fenestration of the false lumen and apposition of two stents on the origins of the arteries respectively. At control angiography after the procedure, all the arteries were patent. After this procedure the patient was admitted and underwent follow up with regular CT scan (6 month). After almost 3 years, on December 2018, the patient came back to our institution with evidence of a Type A aortic dissection at CT scan. After an accurate interrogation the patient seems to have been affected by undefined feeling of chest pain once, some weeks before. The pain wasn’t so intense as to arouse suspicion, even considering the previous presentation and meticulous counseling after the first aortic dissection and, in this way, probably was mistaken for muscular pain or even flu. So the patient decided to wait for the next scheduled CT scan check-up and after telling the story he was immediately sent to our unit. In order to clarify indications for surgery the patient underwent an preoperative echocardiography that confirmed normal left ventricular (LV) function with mild aortic regurgitation. The quality of CT scan was also good enought to show an haematoma/dissection round the right coronary ostium. The haematoma seemes to involve the coronary artery with preservation of intracoronary flow. ( Fig.1). Moreover, we were in possession of fenestration procedure performed near three years before with no signs of coronary artery disease. An preoperatory ECG was normal, as well as levels of troponines. No signs of diskinesia or akinesia were observed at 2D echocardiography but an imagine of intramural haematoma alongside the right coronary ostia. (Fig2).