Atypical Presentation and Intraoperative Complication in a Case of Aortic Dissection

A 68-year-old man, ex-smoker, with a history of hypertension, hypercholesterolemia, and intermittentclaudication secondary to severe aorto-iliac occlusive disease, was evaluated by a cardiologist for exertionalright-shoulder pain of one year's duration. The pain would typically last approximately five minutes andresolve with cessation of activity. He experienced no similar episodes at rest. There was no retrosternal chestpain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, palpitations, transient ischemic attacks,syncope, or pre-syncope. His medications included Norvasc, Prinivil, Novoflupam, Nitrospray, Novo-Timol,Pravacho, Entrophen, and Tylenol. Family history was positive for coronary artery disease. On physical examination, the patient was in no apparent distress with a blood pressure of 160/80 in both armsand a regular pulse of 70. There was a left carotid bruit. Femoral pulses were nearly absent bilaterally. Heartsounds were normal, with no murmurs, and there were no signs of heart failure. EKG showed normal sinusrhythm and no evidence of ischemia or previous infarction. However, thallium scan revealed a fixed deficit inthe inferior wall territory.