Suspected case of subacute stent thrombosis referred for coronary angiography turns out to be unusual aortic dissection presentation

Acute aortic dissection (AAD) is a life-threatening condition requiring early diagnosis and treatment. Even in quickly diagnosed cases mortality remains high. According to data from the International Registry of Acute Aortic Dissection (IRAD) the in-hospital mortality rate in patients with type A AAD (AAAD) was 22%, and mortality of patients managed surgically was 18% [1]. AAAD occurs when a tear develops in the ascending part of the aorta and it is a rare cause of chest pain. More frequently patients with chest pain are suspected to suffer from an acute coronary syndrome (ACS). We present a case of a patient with AAAD who was initially mistakenly diagnosed with ACS secondary to stent thrombosis (ST).
A 59-year-old man with history of smoking, hypertension, heart failure in class II and recent acute myocardial infarction (AMI) was admitted to hospital due to recurrent chest pain. Seven days before admission the patient was discharged from another hospital with diagnosis of anterolateral ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) with implantation of three stents to the left anterior descending artery and two stents to the right coronary artery.
During that hospitalization, transthoracic echocardiography (TTE) showed normal global left ventricular (LV) contractility and ejection fraction of 55%. Additionally, LV hypertrophy and dilatation of the aortic root and the ascending aorta (up to 50 mm and 48 mm respectively) were observed. Then he was discharged and he was prescribed dual antiplatelet therapy (DAPT), typical treatment after AMI, and he received referral for a computed tomography (CT) scan of the aorta. However, now, after 7 days, the patient returned to the hospital with recurrent severe chest pain lasting since morning hours and radiating to the shoulders. The patient reported that he had not bought the prescribed medications due to financial problems. The electrocardiogram (ECG), which was different from the discharge ECG, showed new ST-segment elevation (STE) up to 2 mm and a biphasic T wave in anterior leads. The laboratory test revealed a dynamic increase of cardiac troponin (cTn) levels and the patient was transferred to our tertiary care hospital for urgent coronary angiography (CAG). On admission in the cardiac intensive care unit, he reported moderate chest discomfort and intermittent numbness of the right lower limb. His blood pressure (BP) was 110/43 mm Hg in...


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