APCU25CR27 Renal malperfusion syndrome in type b aortic dissection: a silent threat

Introduction Acute aortic dissection accounts for 80-90% of acute aortic syndrome and is classified as Stanford type A or B based on ascending aorta involvement. Type B aortic dissection (TBAD) presents complex clinical challenges with diverse presentations and life-threatening complications.Case Presentation A 74-year-old male with diabetes mellitus, dyslipidemia, and hypertension had chronic Stanford type B aortic dissection diagnosed five years ago. MSCT cardiac showed single-vessel LAD disease. He was managed conservatively following risk–benefit discussion, given his advanced age. The multidisciplinary team advised serial surveillance with CT angiography (CTA) of the thorax. Repeat CTA at three months showed dissecting aneurysm of the aortic arch and descending thoracic aorta with false lumen widening. Echocardiography revealed LVEF of 35% with trivial aortic regurgitation, and he was started on guideline-directed medical therapy for heart failure. At current admission, he presented with sudden-onset shortness of breath, abdominal pain, and two episodes of vomiting. On arrival, his blood pressure was 168/114 mmHg, heart rate 72 bpm, respiratory rate 40/min, and SpO&noentity8322; 80% on room air. Examination revealed bilateral lung crepitations, soft non-tender abdomen, and no neurological deficit. His renal function rapidly deteriorated, with creatinine rising from baseline 118 µmol/L to 1,192 µmol/L over five days. Serum lactate was normal. Chest X-ray showed widened mediastinum. Given the rapidly worsening renal function, renal malperfusion syndrome was suspected. Emergency CTA revealed Stanford type B aortic dissection extending from the aortic arch isthmus to descending thoracic aorta, with thoracic leakage and active intra-thrombus bleeding at the suprarenal abdominal aorta. The patient declined surgery and subsequently died.Discussion Branch vessel malperfusion is a potentially devastating complication of acute aortic dissection, arising from static, dynamic, or combined obstruction. Rapidly worsening renal function was the sole clue to TBAD with malperfusion in this patient, underscoring the need for prompt recognition and intervention.Conclusion Complicated type B aortic dissection, particularly when associated with branch vessel malperfusion, carries high morbidity and mortality. Optimal outcomes depend on rapid recognition, timely medical management, and urgent surgical or endovascular intervention when indicated. In chronic TBAD with acute symptoms of malperfusion, rupture, or progression of disease, emergency intervention is recommended.