Thrombosed Type B Aortic Dissection: An Uncomplicated Appearance with a Fatal Outcome

Thrombosed Type B Aortic Dissection: An Uncomplicated Appearance with a Fatal Outcome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Thrombosed Type B Aortic Dissection: An Uncomplicated Appearance with a Fatal Outcome Z.HAMDANI, EM.Rochd, H.Hatim, S.Arous, A.Drighil, R.Habbal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6843673/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aortic dissection remains a critical cardiovascular emergency with high mortality. We present the case of a 68-year-old male, a chronic smoker without known hypertension, who arrived with sudden back and lumbar pain. Initial examination showed stable vital signs and no neurological abnormalities. Transthoracic echocardiography identified a double aortic wall, raising suspicion for a thrombosed false lumen. Subsequent CT angiography confirmed a type B aortic dissection with a thrombosed lumen, spanning from the thoracic to the suprarenal abdominal aorta. Medical management using beta-blockers and ACE inhibitors was initiated. Despite apparent initial stability, the patient suffered a sudden cardiac death. This case underscores the unpredictable nature and potential severity of type B aortic dissections, even in the absence of classic risk factors. Cardiac & Cardiovascular Systems Aortic dissection Type B dissection False lumen thrombosis Sudden death Smoking Computed tomography Figures Figure 1 INTRODUCTION Acute aortic syndromes, including dissection, are infrequent but carry high lethality. Their diagnosis may be missed when classical features such as hypertension or pulse deficits are lacking. Type B aortic dissection, which involves only the descending aorta, is typically managed with medical therapy in the absence of complications. Nonetheless, even thrombosed forms can have serious outcomes. This report highlights the case of a smoker without prior hypertension, whose dissection presented atypically and led to a fatal outcome despite guideline-based treatment. CASE PRESENTATION A 68-year-old male with a 27 pack-year smoking history presented to the emergency department with acute lumbar and interscapular pain. He denied any chest pain, dyspnea, or syncope. His medical background was unremarkable, with no known history of hypertension, diabetes, or dyslipidemia. Upon examination, the patient was fully conscious, with stable hemodynamic parameters: blood pressure 130/75 mmHg, heart rate 88 bpm, and oxygen saturation of 98% on room air. No signs of neurological deficit or pulse discrepancies were noted. Cardiopulmonary and abdominal examinations were normal. Routine blood tests, including complete blood count, renal function, and inflammatory markers, were within reference ranges. A transthoracic echocardiogram revealed a double lumen appearance of the descending thoracic aorta, suggestive of a thrombosed false lumen, with no evidence of pericardial effusion. Emergency CT angiography confirmed a type B aortic dissection, involving a thrombosed false lumen extending from the descending thoracic aorta to the suprarenal abdominal aorta (Fig. 1 ). In the absence of rupture, malperfusion, or persistent pain, a conservative approach was chosen. The patient was started on beta-blockers and ACE inhibitors to achieve target heart rate and blood pressure. DISCUSSION Acute type B aortic dissection represents roughly 25–40% of all dissection cases [ 1 ]. Classically, hypertension is the leading risk factor, but cases in smokers without hypertension, as illustrated here, are increasingly recognized [ 2 ]. Smoking may contribute independently to aortic wall degeneration through inflammatory and oxidative mechanisms [ 3 ]. In type B dissection, medical management is preferred initially when there is no rupture, malperfusion, or refractory pain, as per the 2023 European Society of Cardiology guidelines [ 4 ]. The therapeutic objective is to achieve tight regulation of cardiovascular parameters, specifically maintaining the heart rate below 60 beats per minute and systolic blood pressure within the 100–120 mmHg range, with beta-blockers recommended as the first-line treatment [ 4 ]. Thrombosed false lumens have historically been considered more favorable prognostically than patent ones. However, recent data challenge this view, showing that thrombosed type B dissections can still carry significant risks of late aneurysmal degeneration or rupture [ 5 ]. Sudden cardiac death in this context could be related to late expansion, rupture, arrhythmic complications, or cardiac tamponade secondary to extension. Without autopsy, the exact mechanism remains speculative. This case underlines several key teaching points: Aortic dissection can occur without traditional risk factors like hypertension. Smoking is a significant and underestimated risk factor for aortic disease. Even with optimal medical therapy, thrombosed type B dissections require close monitoring, and sudden deterioration remains possible. CONCLUSION This case highlights the unpredictable nature of type B thrombosed aortic dissection and the importance of vigilant monitoring even under medical therapy. Early diagnosis and strict control of cardiovascular parameters are essential, but they do not eliminate the risk of fatal outcomes, especially in vulnerable populations such as active smokers. Declarations PATIENT CONSENT STATEMENT Written informed consent was obtained from the patient for publication of this case report and accompanying images. CONFLICT OF INTEREST The authors declare that they have no conflict of interest. FUNDING This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References Evangelista A, Isselbacher EM, Bossone E et al (2018) Insights from the International Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research. Circulation 137(17):1846–1860 Howard DPJ, Banerjee A, Fairhead JF et al (2013) Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control. Circulation 127(20):2031–2037 Miura S, Saku K (2007) Smoking and Aortic Diseases. Circ J 71(8):1173–1177 Mazzolai L, Teixido-Tura G, Lanzi S et al (2024) 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 45(36):3538–3700 Tolenaar JL, van Keulen JW, Trimarchi S, Jonker FHW, van Herwaarden JA, Verhagen HJM, Moll FL (2013) Muhs BE. Number of Entry Tears Is Associated With Aortic Growth in Type B Dissections. Annals of. Thorac Surg 96(1):39–42 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6843673","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":467961183,"identity":"9359dfb4-b8ea-4685-a44d-44490e4ad0e2","order_by":0,"name":"Z.HAMDANI","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYBACAyCWACMGxgYgspEDiR54QIKWNGOwlgTCWqCAseFwYgOIgU+LOfvpxBs/d1gwyLc3tz34uIM5fX7Y4YdAW+zkdBuwa7Hsyd1s2XtGgoGx52C74cwzbLkbb6cZALUkG5sdwOGwA7nbJHjbJBiYJRLbpHnbeHI3zk4AaTmQuA2XlvNvt0n+BWphk3/YJg1kpBvOTv+AX8uN3G3SIFt4JBjbpBnbDBLkpXMI2HLj7WZr2TYJHgmexDbJ3jMJhhukcwoOJBjg8cv53I0337bVycm3H38m8XPHf3n52embP3yosJPDpQUGeJACBEziV44K5BtIUT0KRsEoGAUjAQAAsdRhmIBLUn8AAAAASUVORK5CYII=","orcid":"","institution":"Centre hospitalier IBN ROCHD","correspondingAuthor":true,"prefix":"","firstName":"","middleName":"","lastName":"Z.HAMDANI","suffix":""},{"id":467961184,"identity":"04ce3a89-7a23-4a4a-9b78-3a2da2104124","order_by":1,"name":"EM.Rochd","email":"","orcid":"","institution":"Centre hospitalier IBN ROCHD","correspondingAuthor":false,"prefix":"","firstName":"","middleName":"","lastName":"EM.Rochd","suffix":""},{"id":467961194,"identity":"b2a2e24d-267c-42b0-b43c-85fe220371a4","order_by":2,"name":"H.Hatim","email":"","orcid":"","institution":"Centre hospitalier IBN ROCHD","correspondingAuthor":false,"prefix":"","firstName":"","middleName":"","lastName":"H.Hatim","suffix":""},{"id":467961266,"identity":"ab672582-5307-49ee-9a50-6bcc75a248d9","order_by":3,"name":"S.Arous","email":"","orcid":"","institution":"Centre hospitalier IBN ROCHD","correspondingAuthor":false,"prefix":"","firstName":"","middleName":"","lastName":"S.Arous","suffix":""},{"id":467961295,"identity":"e10b6a84-07ae-4b31-b922-cdc387d0173d","order_by":4,"name":"A.Drighil","email":"","orcid":"","institution":"Centre hospitalier IBN ROCHD","correspondingAuthor":false,"prefix":"","firstName":"","middleName":"","lastName":"A.Drighil","suffix":""},{"id":467961319,"identity":"0c070519-d1f2-4272-8ff0-b6e16af83bac","order_by":5,"name":"R.Habbal","email":"","orcid":"","institution":"Centre hospitalier IBN ROCHD","correspondingAuthor":false,"prefix":"","firstName":"","middleName":"","lastName":"R.Habbal","suffix":""}],"badges":[],"createdAt":"2025-06-07 15:32:12","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6843673/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6843673/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84423634,"identity":"8a58f835-99ad-4adf-8acd-4f24fd02494a","added_by":"auto","created_at":"2025-06-11 18:49:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1315363,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography angiography images in axial and coronal planes (red arrows) and transthoracic echocardiography views (blue stars) demonstrating a type B aortic dissection. The images highlight the intimal flap and thrombosed false lumen localized in the descending thoracic aorta, with no involvement of the ascending aorta.\u003c/p\u003e","description":"","filename":"image.png","url":"https://assets-eu.researchsquare.com/files/rs-6843673/v1/1b7ed703095a9d0bf4ca217a.png"},{"id":84424163,"identity":"dea74be3-c569-450f-8b2c-b39247d9c655","added_by":"auto","created_at":"2025-06-11 18:57:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1939224,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6843673/v1/deded62c-5295-448e-9d16-8d04b43baad9.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eThrombosed Type B Aortic Dissection: An Uncomplicated Appearance with a Fatal Outcome\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAcute aortic syndromes, including dissection, are infrequent but carry high lethality. Their diagnosis may be missed when classical features such as hypertension or pulse deficits are lacking. Type B aortic dissection, which involves only the descending aorta, is typically managed with medical therapy in the absence of complications. Nonetheless, even thrombosed forms can have serious outcomes. This report highlights the case of a smoker without prior hypertension, whose dissection presented atypically and led to a fatal outcome despite guideline-based treatment.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 68-year-old male with a 27 pack-year smoking history presented to the emergency department with acute lumbar and interscapular pain. He denied any chest pain, dyspnea, or syncope. His medical background was unremarkable, with no known history of hypertension, diabetes, or dyslipidemia. Upon examination, the patient was fully conscious, with stable hemodynamic parameters: blood pressure 130/75 mmHg, heart rate 88 bpm, and oxygen saturation of 98% on room air. No signs of neurological deficit or pulse discrepancies were noted. Cardiopulmonary and abdominal examinations were normal. Routine blood tests, including complete blood count, renal function, and inflammatory markers, were within reference ranges.\u003c/p\u003e \u003cp\u003eA transthoracic echocardiogram revealed a double lumen appearance of the descending thoracic aorta, suggestive of a thrombosed false lumen, with no evidence of pericardial effusion. Emergency CT angiography confirmed a type B aortic dissection, involving a thrombosed false lumen extending from the descending thoracic aorta to the suprarenal abdominal aorta (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the absence of rupture, malperfusion, or persistent pain, a conservative approach was chosen. The patient was started on beta-blockers and ACE inhibitors to achieve target heart rate and blood pressure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAcute type B aortic dissection represents roughly 25\u0026ndash;40% of all dissection cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Classically, hypertension is the leading risk factor, but cases in smokers without hypertension, as illustrated here, are increasingly recognized [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Smoking may contribute independently to aortic wall degeneration through inflammatory and oxidative mechanisms [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn type B dissection, medical management is preferred initially when there is no rupture, malperfusion, or refractory pain, as per the 2023 European Society of Cardiology guidelines [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe therapeutic objective is to achieve tight regulation of cardiovascular parameters, specifically maintaining the heart rate below 60 beats per minute and systolic blood pressure within the 100\u0026ndash;120 mmHg range, with beta-blockers recommended as the first-line treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThrombosed false lumens have historically been considered more favorable prognostically than patent ones. However, recent data challenge this view, showing that thrombosed type B dissections can still carry significant risks of late aneurysmal degeneration or rupture [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSudden cardiac death in this context could be related to late expansion, rupture, arrhythmic complications, or cardiac tamponade secondary to extension. Without autopsy, the exact mechanism remains speculative.\u003c/p\u003e \u003cp\u003eThis case underlines several key teaching points:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAortic dissection can occur without traditional risk factors like hypertension.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSmoking is a significant and underestimated risk factor for aortic disease.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEven with optimal medical therapy, thrombosed type B dissections require close monitoring, and sudden deterioration remains possible.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis case highlights the unpredictable nature of type B thrombosed aortic dissection and the importance of vigilant monitoring even under medical therapy. Early diagnosis and strict control of cardiovascular parameters are essential, but they do not eliminate the risk of fatal outcomes, especially in vulnerable populations such as active smokers.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePATIENT CONSENT STATEMENT\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEvangelista A, Isselbacher EM, Bossone E et al (2018) Insights from the International Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research. Circulation 137(17):1846\u0026ndash;1860\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoward DPJ, Banerjee A, Fairhead JF et al (2013) Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control. Circulation 127(20):2031\u0026ndash;2037\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiura S, Saku K (2007) Smoking and Aortic Diseases. Circ J 71(8):1173\u0026ndash;1177\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMazzolai L, Teixido-Tura G, Lanzi S et al (2024) 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 45(36):3538\u0026ndash;3700\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTolenaar JL, van Keulen JW, Trimarchi S, Jonker FHW, van Herwaarden JA, Verhagen HJM, Moll FL (2013) Muhs BE.\u003cem\u003eNumber of Entry Tears Is Associated With Aortic Growth in Type B Dissections.\u003c/em\u003eAnnals of. Thorac Surg 96(1):39\u0026ndash;42\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Centre Hospitalier Universitaire Ibn Rochd","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Aortic dissection, Type B dissection, False lumen thrombosis, Sudden death, Smoking, Computed tomography","lastPublishedDoi":"10.21203/rs.3.rs-6843673/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6843673/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAortic dissection remains a critical cardiovascular emergency with high mortality. We present the case of a 68-year-old male, a chronic smoker without known hypertension, who arrived with sudden back and lumbar pain. Initial examination showed stable vital signs and no neurological abnormalities. Transthoracic echocardiography identified a double aortic wall, raising suspicion for a thrombosed false lumen. Subsequent CT angiography confirmed a type B aortic dissection with a thrombosed lumen, spanning from the thoracic to the suprarenal abdominal aorta. Medical management using beta-blockers and ACE inhibitors was initiated. Despite apparent initial stability, the patient suffered a sudden cardiac death. This case underscores the unpredictable nature and potential severity of type B aortic dissections, even in the absence of classic risk factors.\u003c/p\u003e","manuscriptTitle":"Thrombosed Type B Aortic Dissection: An Uncomplicated Appearance with a Fatal Outcome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-11 18:41:33","doi":"10.21203/rs.3.rs-6843673/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f796f49d-f59d-404a-a504-725e257b7ac1","owner":[],"postedDate":"June 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":49687343,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2025-06-11T18:41:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-11 18:41:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6843673","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6843673","identity":"rs-6843673","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}