Case 4–1991 A 57-year-old man requires complex management for surgery on a dissecting thoracic aortic aneurysm

A 57-year-old man was referred from an outside hospital with the diagnosis of a dissecting thoracic aneurysm. Six weeks earlier he visited an emergency room because of the sudden onset of severe chest pain. Examination showed no significant physical abnormalities and no evidence of a myocardial infarction. He was discharged on oral nifedipine and nitroglycerin. Over the next several days, he continued to complain of intermittent chest pain, ankle edema, and a lo-lb weight gain. Two weeks after the initial episode, he again complained of acute, severe chest pain and shortness of breath. Emergency room examination showed hypertension and a widened mediastinum on chest x-ray leading to a presumptive diagnosis of a dissecting thoracic aneurysm. Computed axial tomography (CAT) showed a type III aneurysm starting at the left subclavian artery and continuing below the diaphragm. Cardiac catheterization with coronary angiography showed mild atherosclerotic plaqueing in all coronary arteries and an ejection fraction of approximately 40%. After angiography, he developed acute, nonoliguric renal failure that required hemodialysis for several days through a temporary venovenous catheter. One year before the present illness, during an evaluation for hypertension and claudication, he was found to have an occluded abdominal aorta, left renal artery stenosis, and a small left kidney. A left nephrectomy was performed but aortofemoral bypass was refused. On admission, the patient was alert and in no acute distress. His blood pressure was 180/80 mm Hg and heart rate was 84 beats/min with no palpable femoral or other lower extremity pulses. He weighed 63 kg. Neurological examination was normal. Abnormal laboratory analyses included hematocrit (28%) and creatinine (3.0 mg/dL). Before admission the patient had been taking regular oral