A 58-year-old man was hospitalized with acute type B aortic dissection complicated by a right-sided hemothorax, severe hypotension, and cardiovascular syphilis. The life-threatening emergency required immediate circulatory stabilization, thoracic endovascular aortic repair using three tubular stent grafts, and surgical evacuation of the mediastinal hematoma.
Emergency Admission and Hemodynamic Stabilization
The patient arrived at the Emergency Department presenting with a qualitative disturbance of consciousness, severe hypotension with a systolic pressure of 40 mmHg, and agonizing pain in the epigastrium and the bottom part of the left hemithorax. Described as a 58-year-old white male with a history of chronic alcohol abusus, he reported experiencing slight chest pain during the preceding months according to clinical records. Upon admission, he was soporous, and an electrocardiogram revealed sinus tachycardia reaching up to 180/min alongside clinical signs of dehydration.
Medical personnel stabilized his blood circulation, achieved spontaneous ventilation, and restored full consciousness through the intravenous administration of 2,500 milliliters of crystalloids, supplemented by temporary circulatory support using noradrenalin. Laboratory findings identified normochromic, normocytic anemia with a hemoglobin level of 93 g/L, while other routine laboratory tests returned normal results.
Diagnostic Imaging and Rare Complications
Echocardiographic examination revealed significant extrapericardial oppression of the left atrium, moderate aortic regurgitation accompanied by slight dilatation of the ascending aorta, and a right-sided fluidothorax. Suspecting an acute aortic dissection, clinical teams performed urgent computed tomography angiography following established diagnostic pathways. The imaging exposed an intramural hematoma of the descending aorta measuring 85 × 37 × 60 mm, communicating directly into the right pleural cavity to form a hemothorax.
Furthermore, the scans confirmed that a mediastinal hematoma was compressing the left atrium and pulmonary veins. Physicians also discovered another chronic intramural hematoma dorsally at the transition of the arch and the descending aorta. Additional diagnostic evaluations revealed tertiary stage of syphilis, confirmed by positive serological tests in both blood and cerebrospinal fluid, identifying cardiovascular syphilis as the probable causal agent.
Surgical Intervention and Postoperative Recovery
To address the life-threatening tear, specialists excluded the affected section of the thoracic aorta using three tubular stent grafts with the proximal stent graft overlapping left subclavian artery. A type II endoleak that developed during the procedure was resolved by embolizing the proximal part of the left subclavian artery using coils. Six days later, surgeons surgically evacuated the remaining hematomas from the right pleural cavity through a right-sided thoracotomy.
During recovery, the patient experienced slight dysphagia. Swallowing evaluations demonstrated a left-sided ventrolateral deviation of the esophagus caused by pressure from the descending aorta’s intramural hematoma, though no obstruction was present, allowing for a conservative management approach. Following targeted antibiotic treatment for the underlying luetic infection, the patient was discharged for outpatient treatment and remained registered at the dispensary.
