Successful Medical Management of an Acute Ascending Aortic Dissection After Coronary Artery Bypass Graft Surgery

Abstract

Aortic dissection is an acute and life-threatening disease entity. Mortality rates increase every hour after the presentation. Typical treatment includes medical management of blood pressure and heart rate control followed by prompt transfer to an operating room for surgical repair. We present a case of medically managed Stanford type A aortic dissection in a postoperative coronary artery bypass graft (CABG) patient. A 77-year-old man with a past medical history of hypertension and hyperlipidemia presented after an outpatient nuclear stress test demonstrated a reversible inferior wall defect. He was subsequently referred to a cardio-thoracic surgeon and underwent coronary artery bypass graft (CABG) surgery. Three weeks later, the patient presented to the emergency department complaining of a productive cough, nausea, vomiting, and fever. He was diagnosed with sepsis secondary to pneumonia. A CT chest demonstrated a new 3.9 cm long segment of dissection in the ascending thoracic aorta. Due to postoperative recovery from recent CABG, a decision was made to treat the ascending thoracic aortic dissection (Stanford type A) medically. He was advised to continue intensive antihypertensive medications and close follow-up with a cardiologist and cardiothoracic surgeon on an outpatient basis. Subsequent follow-up CT chest angiography at one month, four months, and 12 months later did not demonstrate the progression of the ascending aortic dissection. Decisions to deviate from the usual care should best be taken in a multidisciplinary team approach. Patients should clearly be informed about the rationale behind these complex decisions.