History and clinical findings: A 51-year-old man, having experienced sudden retrosternal pain was admitted to another hospital with suspected myocardial infarction. He also had dysaesthesia and later paresis of the left leg. There was no sign of acute infarction in the ECG. However, computed tomography revealed aortic dissection, type III (DeBakey). The left pedal pulses were diminished. The patient was transferred to our hospital for further diagnosis and treatment. At a blood pressure of 110/60 mm Hg the occlusion pressure of the leg artery was 55 mm Hg on the left and 95 mm Hg on the right.
Investigations: Transoesophageal echocardiography detected no abnormality of the aortic valve and ascending aorta. But distal to the origin of the left subclavian artery it demonstrated a free floating membrane of an aortic dissection and computed tomography showed its extension to the aortic bifurcation.
Treatment and course: At first, because of the incomplete ischaemia syndrome affecting the left leg, a percutaneous fenestration of the dissection membrane was performed. After conventional angiography intravascular ultrasound imaging was also undertaken; it revealed that the membrane was almost completely occluding the left iliac artery. Under ultrasound monitoring a puncture needle and two balloon catheters were introduced across the membrane and thus a window created in it. The clinical findings quickly disappeared and the patient was discharged without further operation.
Conclusion: Monitoring with intravascular ultrasound imaging makes it possible to perform safely a percutaneous fenestration of the membrane of an aortic dissection and to obtain immediate evidence of its success.