Aorto-coronary dissection during angioplasty in a patient with myxedema

Aortic dissection and renal failure in a patient with severe hypothyroidism

Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality. The most important recognized acquired cause that leads to dissection is chronic arterial hypertension. With respect to the anuria and renal failure, aortic dissection is not something that is always considered and is still not a very common presentation unless both renal arteries come off the false lumen of the dissection. However, when present, preoperative renal failure in patients with acute type B dissection has been noted to be an independent predictor of mortality. Early recognition and diagnosis is the key and as noted by previous studies as well, almost a third of these patients are initially worked up for other causes until later when they are diagnosed with aortic dissection. Here we present a case of a patient presenting with severe hypothyroidism, long-standing hypertension, and anuria. Through the case, we highlight the importance of having aortic dissection as an important differential in patients presenting with anuria who have a long standing history of uncontrolled hypertension. Pathophysiology relating to severe hypothyroidism-induced renal dysfunction is also discussed.

Fracture of popliteal artery stents

In peripheral arterial obstructive disease, more than 50% of all lesions are localized in the femoropopliteal segment and surgical revascularization is the treatment of choice. Percutaneous transluminal angioplasty (PTA) is recommended for short lesions, with subsequent stent implantation if the result is sub-optimal or dissections occur after PTA or for restenosis. There are both acute and late complications with stent implantation. In the present patient, stents were placed in the left popliteal artery where the left knee joint flexes, and obstruction because of stent fracture occurred 6 months later. The patient eventually underwent left femoro-popliteal saphenous vein bypass grafting.

A case of delayed shock due to dissection of the hyperplastic coronary artery after balloon angioplasty and stenting

A 42-year-old obese woman with a history of liver cirrhosis and diabetes mellitus was admitted because of chest pain. Coronary balloon angioplasty and stenting were performed on the left anterior descending artery (LAD), which was 90% stenotic. She developed moderate shock about 6h later, and about 15 h after the procedure, she died from excessive bleeding from the right femoral artery because of removal of the catheter sheath by herself. Autopsy disclosed haemorrhagic cardiac tamponade and extensive haemorrhage into the epicardial adipose tissue, however, neither coronary perforation nor myocardial rupture was recognized. Histological examination of the dilated coronary segment revealed extensive dissection with an eccentric intimal thickening and the disruption of the adventitia. It was thought to be the origin of the haemorrhage. Although coronary dissection is a well-known complication during cardiac catheterization procedures, this report describes a rare fatal case with delayed onset of shock due to coronary dissection caused by balloon angioplasty and stenting in the presence of eccentric hyperplasia of the vessel wall.