A case of “tearing” back pain and acute limb ischaemia

Search all BMJ education articles:

From

Limit by

The BMJ iPad app brings you the best of print and online, including live links to the latest news, blogs, video, and podcasts. Get the BMJ iPad app.
You can use bmj.com to help you with your continuing medical education. Find out about CME/CPD credits for BMJ articles
Rapid responses are electronic letters to the editor and new ones are published each day. Read latest responses.

Access to the full text of this article requires a subscription or payment. Please log in or subscribe below.

R Allison, specialist registrar in radiology1,
M G Wyatt, consultant vascular surgeon2,
R Williams, consultant interventional radiologist1

¹Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne NE7 7DN
²Department of Vascular Surgery, Freeman Hospital

Correspondence to: M G Wyatt mike.wyatt{at}nuth.nhs.uk

A 50 year old man presented to his local accident and emergency department with sudden onset of severe “tearing” interscapular back pain and a cold white insensate left leg. At initial assessment he had pronounced hypertension, an ischaemic left leg, and an impalpable left femoral pulse. His medical history was unremarkable. An urgent computed tomography angiogram was obtained (fig 1⇓).

Fig 1 Three dimensional reconstruction from the computed tomography angiogram showing the aortic arch and the iliac bifurcation

Questions

1 What is the diagnosis?
2 What is the most common classification system, and how would you classify this case?
3 What complication does the patient have?
4 What are the treatment options?

Answers

Short answers

1 The angiogram shows a thoracic aortic dissection (fig 2⇓).

Fig 2 Three dimensional reconstruction from the computed tomography angiogram showing the aortic arch and the iliac bifurcation. The left arrow shows the intimal flap and the right arrow indicates the occluded left commom iliac artery

2 The most common classification system is the Stanford classification. This is a Stanford type B dissection. It starts distal to the left subclavian artery.
3 The intimal flap has occluded the left common iliac artery causing acute ischaemia of the left leg.
4 Complicated type B dissections should be treated by endovascular insertion of an aortic stent graft or open surgery to replace the affected aortic segment. Uncomplicated dissections should be treated by aggressive blood pressure management.