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\begin{document}

\title{Stanford type A acute aortic dissection associated with aircraft
depressurization: Cause or coincidence?}



\author[1]{Mauer Gonçalves}%
\author[2]{Humberto Morais}%
\author[3]{Valdano Manuel}%
\author[4]{Fernando Coelho}%
\author[4]{Sheila Gonçalves}%
\author[4]{Fernando Flora}%
\affil[1]{Centro de estudos Avançados em Educação e Formação Médica, Universidade Agostinho Neto}%
\affil[2]{Hospital Militar Principal/Instituto Superior}%
\affil[3]{Clin Girassol}%
\affil[4]{Luanda Medical Center}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\textbf{Stanford type A acuteaortic dissection associated with aircraft
depressurization: Cause or coincidence?}

Mauer A.A. Gon\selectlanguage{ngerman}çalves\textsuperscript{1,2}; Humberto
Morais\textsuperscript{2,3}; Valdano Manuel\textsuperscript{4}; Fernando
Coelho\textsuperscript{1}, Sheila Nunes\textsuperscript{1}, Fernando
Flora\textsuperscript{1}.

\textsuperscript{1}Luanda Medical Center, Angola;

\textsuperscript{2}Centro de Estudos Avançados em Educação e Formação
Médica, Faculdadede Medicina, Agostinho Neto University, Luanda, Angola

\textsuperscript{3}Hospital militar Principal/Instituto Superior

\textsuperscript{4}Centro cardiotorácico, Hospital de Doenças
Cardiopulmonares Don Alexandre do Nascimento

Corresponding Author: *Humberto Morais -- Hospital Militar
Principal/Instituto Superior,

Rua Pedro Miranda 40-42 Maianga Luanda Republic of Angola

Email: hmorais1@gmail.com Telephone: +244923520937

We declare that the patient approved the study by signing an informed
consent form and the study followed the ethical guidelines established
by the Declaration of Helsinki.

\textbf{Abstract}

We report the case of a 82-year-old woman, known to have hypertension,
who was admitted to the emergency department of Luanda Medical Center
for chest pain 24 hours after an episode of commercial aircraft
depressurization and whose thoraco-abdominal CT revealed a Stanford type
A acute aortic dissection.

\textbf{Key clinical message}

Elderly patients who present at emergence department with chest pain
after an episode of depressurization in the cabin of a commercial
airplane deserve special attention in order to exclude acute aortic
syndrome

\textbf{Keywords:} aortic dissection, Airplane cabin depressurization;
Cardiac surgery

\textbf{Introdution}

Acute ascending aortic dissection is an uncommon disease that causes
tragic loss of life if not treated emergently. Therefore, having a high
index of clinical suspicion is crucial for better survival {[}1{]}.
Here, we present a case of Stanford type A acute aortic dissection (AAD)
associated with commercial airplane despressurization.

\textbf{Case presentation}

An 82-year-old female, autonomous in activities of daily living, with a
history of arterial hypertension dyslipidemia, and chronic venous
insufficiency medicated with Losartan 50mg/day Simvastatin 20mg/day and
Daflon was admitted to the emergency department (ED) of the Luanda
Medical Center because she woke up complaining of excruciating chest
pain radiating to the back, associated with tiredness. A day earlier, he
mentions that on an airplane trip, during the flight there was
depressurization in the cabin, causing him a lot of stress and anxiety.
Since then she started to feel chest discomfort.

On arrival at the ED, the patient was very complaining, tachypneic,
respiratory rate = 28 cycles/min, Sat O2 87\% in ambient air, rising to
93\% with 3 L of O2 through nasal cannula. BP was 120/70 mmHg, with a
pulse 70 bpm, and normal cardiac auscultation. Pulmonary auscultation:
diminished vesicular sound with wheezes. Slight edema in the lower
limbs. Peripheral pulses are present and symmetric.

Labs: Hb 10.0 g/L, D-dimers 32.199, values of CK-MB and troponine were
normal. Blood gases: compensated respiratory acidosis with hypoxemia.
Chest Rx (AP-view): Apparent widening of the
mediastinum.Thoracic-abdominal CT angiography shows a Stanford type A
AAD(Figure 1 A).The patient was referred for surgical treatment. The
patient underwent surgical treatment (figure 1B,C), and she died on the
26th postoperative day due to respiratory failure

\textbf{Discussion}

Commercial aircraft generally use flight levels ranging from 30,000 to
40,000 feet (about 9,000 to 12,000 meters). At this altitude, external
effects begin to cause changes in the organism {[}2{]}. Depressurization
can occur when there is a loss of pressure. This can be fast or slow,
being the result of a malfunction in the system or a leak in the
aircraft fuselage.

In cases of depressurization, the symptoms are headache, fatigue
dizziness, nausea vomiting, lack of concentration/confusion extremity
paresthesias and chest pain {[}3{]}. In the case reported herein, it was
a slow depressurization, the patient was subjected to intense emotional
stress and a feeling of panic. During this period the patient
experienced atypical chest discomfort. 24 hours latter the patient
started experiencing chest pain radiating to the back associated with
extreme tiredness. The diagnosis of Stanford type A AADat ED was made.
To the best of our knowledge, there is only one clinical case described
in a fighter pilot instructor who developed an AAD at a height of 230 m
during left drill action of acute spiral down movement from 2000\selectlanguage{english}-m high
attitude driven by an air force pilot trainee{[}1J.

\textbf{Conclusion}

This work deals with a very rare association between the
depressurization of a commercial plane and a Stanford-type A AAD. Our
hypothesis is that cabin depressurization served as a trigger for the
development of AAD, which is supported by the fact that the ascending
aorta diameter is normal for age.

\textbf{Conflict of interest} : The authors declares no conflicts of
interest.

\textbf{Funding} : The author declares no funding to develop this
article.

\par\null

\textbf{References}

\begin{enumerate}
\tightlist
\item
  An J,~Elhenawy AM.Acceleration-induced acute type A aortic dissection
  in the sky: 10-year follow-up.J Card Surg. 2020;35(5):1112-1114. doi:
  10.1111/jocs.14498.
\item
  Muehlemann T, Holper L, Wenzel J, Wittkowski M, Wolf M.The effect of
  sudden depressurization on pilots at cruising altitude.Adv Exp Med
  Biol. 2013;765:177-183. doi: 10.1007/978-1-4614-4989-8\_25.
\item
  Mancini S,~Crotty AM, Cook J.Triage and Treatment of Mass Casualty
  Decompression Sickness After Depressurization at 6400 m.Aerosp Med Hum
  Perform. 2018 Dec 1;89(12):1085-1088. doi: 10.3357/AMHP.5142.2018.
\end{enumerate}\selectlanguage{english}
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Fig. 1A - Thoracoabdominal CT scan revealed Stanford type A acute aortic
dissection extending below the renal arteries AAo- Ascending aorta, DAo
Descending aorta, Flap (blue arrow), PT-Pulmonary trunk, TL - True
lumen, 1B and C - Intraoperative images reveal the thrombosed false
lumen (asterisk), and the Gortex conduit placed in the ascending aorta
(blue ellipse)

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