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Acute Aortic Dissection in Setting of Preeclampia: A Rare, Yet Potentially Deadly Complication
Natalia Ashely Cavagnaro, Vishal Patel, Ali Siddiqui, Eric Trestman, Kousta Foteh, Hunter Ray
HCA Healthcare Kingwood/University of Houston, Kingwood, TX
INTRODUCTION: Acute aortic dissection in pregnancy is rare, occurring in less than 0.0005% of all pregnancies, and representing 0.3% of all aortic dissections. METHODS: We present a 27-year-old female with family history of aortopathy, presenting In her third trimester for management of acute Type B aortic dissection in setting of suspected preeclampsia.RESULTS:A 27-year-old female presenting as a G1P0 at 32 weeks gestation who presented same day to transferring facility with new onset, severe chest pain radiating to the back. CTA showed acute type B aortic dissection extending just distal to the left subclavian down to the level of the right renal artery, and she was transferred for higher level of care. On arrival she met criteria for severe preeclampsia with evidence of intrauterine growth restriction with absent diastolic flow.Given gestational age, uncontrolled hypertension, and slowed fetal heart rate, decision was made by OB team to proceed with urgent cesarean under general anesthesia. She tolerated the procedure well and was transferred to Neuro ICU post operatively for impulse control. She reported resolution of chest and back pain, and repeat CTA appeared stable with patent mesenteric vessels and absence of high risk features. Discussion was held with patient and family regarding TEVAR vs medical therapy, and patient wished to proceed with medical therapy. On POD3, she had acute changes overnight. She reported recurring severe chest and back pain. On exam blood pressure was uncontrolled despite maxed Cardene and Esmolol drip, abdomen was distended and tympanic, and there was evidence of pulmonary congestion and worsening acute renal insufficiency. Repeat scan showed patent mesenteric vessels, but unable to rule out dynamic obstruction of the superior mesenteric artery. At this time patient was determined to have a complicated type B aortic dissection, and decision was made to proceed with emergent TEVAR without LSA coverage. The SMA had 90% stenosis due to false lumen filling, so this was ballooned and stented with excellent results. Completion angiogram demonstrated robust filing of all great and visceral vessels.
CONCLUSIONS: There are few reported cases of acute dissection in the setting of preeclampsia, making diagnosis and management challenging,. Recognition of underlying conditions, timely diagnosis and multidisciplinary care is crucial for this potentially deadly complication.
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