Coarctation of the aorta (CoA) is characterized by congenital narrowing of the aortic isthmus. Primary treatment modalities include balloon dilatation, stenting, and surgical repair. Here, we present the case of a 37-year-old male with refractory hypertension who underwent successful stenting of a severe postductal CoA, achieving complete resolution of the trans-coarctation gradient. Twenty-four hours later, he developed severe inter-scapular pain, and computed tomography aortography revealed an extensive Stanford type B aortic dissection extending from the distal stent margin to beyond the aortic bifurcation. As there were no signs of end-organ malperfusion, conservative management was pursued with close monitoring and blood pressure control. The dissection stabilized and the patient responded favorably, with sustained stability on the follow-up.

Midaortic syndrome (MAS) is a rare vascular disorder characterized by segmental narrowing of the distal thoracic or abdominal aorta, accounting for only 0.5-2% of aortic coarctations. Adult-onset idiopathic MAS is particularly uncommon and typically presents with refractory secondary hypertension, whereas dialysis-dependent acute kidney injury (AKI) is an exceptionally rare manifestation. A 44-year-old man with a history of smoking and alcohol use presented with oliguria, vomiting, left flank pain, severe hypertension (210/110 mmHg), and advanced renal failure (serum creatinine 8.0 mg/dL). Laboratory investigations revealed mild proteinuria, microscopic hematuria, and thrombocytopenia, while autoimmune, infectious, and thrombotic evaluations were unremarkable. Renal biopsy demonstrated moderate acute tubular injury with minimal chronic changes. Despite initiation of hemodialysis and intensive antihypertensive therapy, the patient remained dialysis dependent. Careful re-examination identified diminished lower-limb pulses and a significant upper- to lower-limb blood pressure gradient. CT aortography demonstrated complete occlusion of the abdominal aorta distal to the superior mesenteric artery with extensive bilateral renal collateral circulation, consistent with idiopathic MAS. PET imaging excluded active large-vessel vasculitis, and the absence of significant atherosclerotic disease supported an idiopathic etiology. A repeat renal biopsy again showed acute tubular injury without significant fibrosis or hypertensive vascular changes. Given the preserved collateral renal perfusion, dialysis frequency was gradually reduced and ultimately discontinued. Over the subsequent two weeks, urine output increased to 1.5 L/day, accompanied by progressive recovery of renal function and resolution of volume overload. This case highlights that idiopathic MAS should be considered in adults presenting with refractory hypertension and unexplained dialysis-dependent AKI, particularly when pulse deficits or inter-limb blood pressure discrepancies are present. Extensive collateral renal circulation may preserve renal viability despite complete aortic occlusion. Recognition of this unique hemodynamic physiology may prevent unnecessary prolonged dialysis, as excessive ultrafiltration may compromise collateral-dependent renal perfusion and delay renal recovery.

An 85-year-old bedridden woman (modified Rankin Scale 5) presented with a contained rupture of an acute retrograde aortic dissection (Type B0,7). Because open surgery was prohibitive due to severe frailty, an emergent total endovascular repair was performed using single-branch, retrograde in situ branched stent grafting (RIBS). Two conformable GORE TAG devices established a Zone 1 seal, and the left common carotid artery was preserved by in situ needle fenestration using a percutaneous transhepatic gallbladder drainage needle and bridged with a VIABAHN VBX stent. To limit embolic risk, cerebral blood flow was transiently interrupted by manual right carotid compression, direct left carotid clamping, and left subclavian balloon occlusion. Operative time was 114 minutes, and the postoperative course was uneventful without neurological deficits. One-year computed tomography showed favorable aortic remodeling and no endoleak. Single-branch RIBS may offer an immediate, off-the-shelf salvage option for high-risk patients when open repair is not feasible.

Background Thoracic aortic dissection (TAD) is a rare but often fatal condition if left undiagnosed. This study reviewed the detection rate and clinical presentations of TAD in an urban Australian ED. Methods A retrospective observational study was conducted from October 30, 2018 to March 30, 2023. The hospital imaging database (InteleViewer) was searched for radiology reports containing "aorta" or "aortic" together with "dissection" or the misspelling "disection." The search identified 25 patients with acute TAD who presented to the ED. Medical records were reviewed, and the Aortic Dissection Detection Risk Score (ADD-RS) was applied retrospectively. Cases missed in the ED were also reviewed. Results Nineteen cases (76%) were type A, and six (24%) were type B, corresponding to 8.6 cases per 100,000 ED visits. Hypertension was the most common risk factor (64%). Pain presentations varied, with only five patients (20%) experiencing classic, sudden-onset central chest pain radiating to the back. TAD was diagnosed by CT aortography in 22 cases (88%). Chest radiography was performed in 12 patients and showed signs of TAD in six (50%). Bedside echocardiography was performed in 12 cases and detected TAD in one-third. The median time from ED arrival to surgical intervention was 230 minutes (IQR, 165-480 minutes). Fifteen patients (60%) had an ADD-RS ≤1; however, most did not undergo D-dimer testing. One case was initially missed in the ED but was subsequently diagnosed after hospital admission and had a favourable outcome. Conclusions Our study demonstrates the variability in the presenting features of TAD. Within this cohort, patients with confirmed TAD experienced short intervention times and favourable outcomes. The absence of classic symptoms and ADD-RS features does not exclude a diagnosis of TAD. Improving staff education regarding key symptoms and signs may enhance early detection.

Acute aortic dissection is a vascular emergency with unpredictable progression and outcomes. Standard imaging modalities, such as computed tomography angiography (CTA), facilitate diagnosis and operative planning but provide limited data on vessel wall mechanics and hemodynamics. Modern imaging and computational models may offer deeper insights into natural history prognostication and risk prediction. This PROSPERO-registered systematic review (CRD42024589703) followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Eligible MEDLINE and Embase studies assessed vessel wall dynamics or hemodynamic modeling in healthy or dissected aortas. The risk of bias was assessed using Risk Of Bias In Non-Randomized Studies - of Interventions; the quality of evidence was evaluated with Grading of Recommendations, Assessment, Development and Evaluation. A total of 36 studies were included, mainly retrospective single-center cohort studies of CT/CTA, magnetic resonance imaging, ultrasound, echocardiography, and digital subtraction angiography. An entry tear size greater than 10 mm on CTA was associated with increased false lumen flow and higher sheer wall stress, causing poor aortic remodeling, as confirmed with 4-dimensional magnetic resonance imaging. Distal entry tears and presence of more entry tears reduced the risk of pulsatile-type dissections, having a long-term protective effect. Helical flow patterns assessed through computational fluid dynamics determining kinetic energy transmission increase proximal false lumen thrombosis with favorable outcomes. Modern imaging and modeling techniques demonstrate potential in predicting disease progression, with the possibility of tailoring aortic dissection management. Because most studies were exploratory in design, they could not establish replicable clinical protocols or measurable parameters. Measurements of false lumen flow, kinetic energy, and entry tear features (size and number) have demonstrated the greatest potential. Further prospective, standardized studies are essential to translate these findings into routine clinical care.

Familial hypercholesterolaemia (FH) is a genetic disorder characterised by elevated levels of circulating low-density lipoprotein cholesterol. Serious presentations are challenging to treat. We report a case of complex cardiovascular outcomes in a 28-year-old man with diabetes mellitus and untreated FH. The diagnostic workup was compatible with a homozygous phenotype. The patient presented with a non-ST-elevation myocardial infarction, which revealed severe premature three-vessel coronary artery disease with significant proximal blockages, including severe ostial left main stenosis, as well as severe valvular and supravalvular aortic stenosis. Aortic computed tomography angiography (CTA) confirmed the presence of a porcelain aorta and guided the surgical repair. Despite the porcelain aorta, the patient underwent conventional cardiac and aortic surgery with an uneventful post-operative course. This case highlights a rare case of successful cardiac and aortic surgery in the context of a porcelain aorta, performed safely by experienced surgeons using current perfusion and operative techniques guided by CTA imaging. Ongoing efforts are required to improve early detection and prompt management of FH.

Valve-sparing aortic root replacement is increasingly used in selected patients with acute aortic dissection and preserved valve anatomy. We present the case of a 52-year-old man with acute Stanford type A aortic dissection extending from the aortic root to the iliac bifurcation with arch involvement; this was complicated by severe aortic insufficiency and right lower extremity malperfusion. The patient underwent emergent valve-sparing root replacement using the David technique combined with zone 2 arch reconstruction under hypothermic circulatory arrest and selective antegrade cerebral perfusion. Intraoperative echocardiography confirmed excellent valve function with trace residual regurgitation. The postoperative course was notable for transient vasoplegia and re-exploration without bleeding, followed by uneventful recovery and discharge on postoperative day 11. This case highlights the feasibility of combining valve-sparing root replacement with zone 2 arch reconstruction in the acute setting of Stanford type A dissection with malperfusion, allowing restoration of true lumen flow while preserving native valve function.