CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 7, August 2012
AFRICA
e13
Case Report
Isolated lower limb ischaemia as an unusual presenting
symptom of aortic dissection
CHIH-HSIEN LEE, CHENG-HSI CHANG, YI-TING TSAI, CHING-WEN WU
Abstract
Acute aortic dissection is not common but usually presents
with a severe, sharp chest pain and high blood pressure.
Widening of the mediastinum is usually also evident on chest
X-ray. Although acute onset of severe chest or back pain is
the most common presenting symptom, some patients may
present with atypical symptoms and signs.
Establishing a diagnosis of aortic dissection can be diffi-
cult in the presence of atypical symptoms, especially in the
absence of pain. Such presentation of aortic dissection is
easily ignored. We report a case of painless aortic dissection
with normal blood pressure, which resulted in acute isolated
lower limb ischaemia at presentation.
Atypical presentation of isolated limb arterial occlusions
in an older patient without the classic symptoms are seldom
reported as aortic dissection. However, aortic dissection
should be included in the differential diagnosis of patients
with arterial occlusive disease without chest pain and with
normal blood pressure.
Keywords:
aortic dissection, lower limb ischaemia
Submitted 20/11/11, accepted 15/3/12
Published online 11/4/12
Cardiovasc J Afr
2012;
23
: e13–e14
DOI: 10.5830/CVJA-2012-029
Aortic dissection is a catastrophic disease with variable
presentation. Pain is the most prominent initial symptom and
severe chest pain is the major complaint in 80 to 95% of
patients.
1
However, approximately 6.4 to 14% of aortic dissection
patients presented with painless aortic dissection.
2-4
Isolated
lower extremity ischaemia is an unusual presentation in aortic
dissection. Herein, we report a patient who presented with right
lower extremity ischaemia with neither chest pain nor abdominal
discomfort.
Case report
A 62-year-old man with no previous history, suffered from
sudden-onset parethesia of the right lower limb and chest
tightness without pain. Because of his persistent symptoms, the
patient presented at our hospital for evaluation and treatment.
On initial evaluation, the patient had a right-side blood
pressure of 108/79 mmHg, and left-side blood pressure of
100/70 mmHg. His oral temperature was 36.8°C, pulse rate
was 60 beats/min and respiratory rate was 20/min. Physical
examination revealed neither cardiac murmur nor abnormal
breathing sounds. The muscle power of the right lower limb was
reduced, with diminished pulse at the right femoral artery.
Laboratory tests showed a white blood cell count of 10.53
×
10
3
/
m
l, haemoglobin concentration of 14.4 g/dl, blood
urea nitrogen concentration of 24 mg/dl, blood creatinine
concentration of 1.3 mg/dl, sodium concentration of 141 mEq/l,
and potassium concentration of 2.7 mEq/l. The liver function
tests were normal and other observations were unremarkable.
The ECG showed sinus rhythm. A chest CT scan revealed an
intimal flap and we found Stanford type B aortic dissection (Fig.
1). The diagnosis of the acute dissection was confirmed and the
patient received a sternotomy with elephant trunk. At one-year
follow up he was fine.
Discussion
Acute onset of severe chest or back pain characterised as
‘ripping’ or ‘tearing’ is the most common presenting symptom
of aortic dissection, which typically originates from a primary
Internal Medicine – Acute Illness, Department of Internal
Medicine, Tungs’ Taichung MetroHarbor Hospital, Taiwan
CHIH-HSIEN LEE, MD
Department of Cardiac Surgery, Tungs’ Taichung
MetroHarbor Hospital, Taiwan
CHENG-HSI CHANG, MD
CHING-WEN WU, MD,
Division of Cardiovascular Surgery, Department of Surgery,
Tri-Service General Hospital, National Defense Medical
Centre, Taiwan
CHIH-HSIEN LEE, MD
YI-TING TSAI, MD
Fig. 1. CT scan showing an intimal flap and Stanford type
B aortic dissection.
