Herein, we report an unusual case of a patient who presented to the emergency department with complaints of sudden neck swelling and ecchymosis. The patient was diagnosed with a ruptured type B dissection and treated by endovascular technique. This case is presented due to its rarity and discussed in the light of treatment options based on the literature data.

Figure 1: Large neck ecchymosis extending onto the upper chest wall.

Physical examination revealed a large neck ecchymosis extending onto the upper chest wall. All peripheral pulses were symmetrically palpable and there was no pressure difference between the upper extremities. Neurological examination was unremarkable. Her blood pressure was 160/90 mmHg, heart rate was 112 bpm, respiratory rate was 25 bpm, temperature was 36.5 °C, and oxygen saturation by pulse oximetry was 90% on room air. The hemoglobin level was 9.8 g/dL. A complete blood count demonstrated white blood cell count of 14,300/mm3, hemoglobin level of 9.8 g/dL, and platelet count of 231,000/mm³. Coagulation studies revealed an international normalized ratio (INR) of 1.2.

Computed tomography (CT) examination demonstrated a ruptured type B dissection causing mediastinal and neck hematomas without hemothorax (Figure 2). She was immediately brought to the angiography suite for endovascular treatment. Through left femoral artery, two thoracic endografts (Medtronic Valiant, Medtronic AVE, Santa Rosa, CA) were deployed from just beyond the origin of the left subclavian artery to the mid-descending thoracic aorta. Repeated angiogram did not show any evidence of endoleak at the end of the procedure. She was discharged on the fourth postoperative day. The follow-up CT at one month showed total exclusion of dissection without endoleak and size reduction of the mediastinal hematoma (Figure 3).

Figure 2: Preoperative computed tomography scan showing thoracic aortic dissection and mediastinal hematoma. Arrows highlight mediastinal hematoma and its extension through the thoracic outlet.

Figure 3: Postoperative computed tomography scan showing no evidence of endoleak and size reduction of the mediastinal hematoma.

Acute type B aortic dissection is treated medically, unless complicated by malperfusion, rupture, intractable pain, early false lumen expansion or uncontrolled hypertension. All complicated acute type B dissections require an urgent approach by an open surgical or endovascular intervention. The aim of endovascular repair of complicated aortic dissections is to prevent death from rupture, correction of malperfusion syndromes, and cease diameter expansion of the aneurysm. In a metaanalysis, Parker and Golledge[6] reported an in-hospital mortality incidence of 9%, an emergency surgical conversion rate of 0.6%, a periprocedural stroke rate of 3.1%, a mean 20-month survival of 88%, an endovascular re-intervention rate of 7.6% and a surgical re-intervention rate of 2.8% following endovascular repair of type B aortic dissections. On the other hand, open surgery for acute type B aortic dissection carries a 18 to 22% risk of in-hospital mortality even at experienced centers.[7] Therefore, surgery has been replaced by endovascular repair with a grade 1A recommendation.[7,8]

In conclusion, a ruptured acute type B aortic dissection may present with neck ecchymosis. This unusual presentation should always be kept in mind when managing patients with acute chest pain without any evidence of myocardial ischemia. Endovascular treatment, if applicable, should be considered the first-line treatment in complicated acute type B dissection with favorable initial and long-term outcomes.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

1) Patel AY, Eagle KA, Vaishnava P. Acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection. Ann Cardiothorac Surg 2014;3:368-74.

2) Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet 2015;385:800-11.

3) English P, Kishore M. Aortic dissection and rupture presenting as suprasternal bruising and neck swelling. Age Ageing 2002;31:310-2.

4) Al-Hity W, Playforth MJ. Collapse, hoarseness of the voice and swelling and bruising of the neck: an unusual presentation of thoracic aortic dissection. Emerg Med J 2001;18:508-9.

5) Hashimi S, Bashir M, Suzuki Y, Calcaterra D. Anterior chest ecchymosis from complicated descending thoracic aortic aneurysm. Eur J Cardiothorac Surg 2011;40:1545.

6) Parker JD, Golledge J. Outcome of endovascular treatment of acute type B aortic dissection. Ann Thorac Surg 2008;86:1707-12.

7) Bhamidipati CM, Ailawadi G. Acute complicated and uncomplicated type III aortic dissection: an endovascular perspective. Semin Thorac Cardiovasc Surg 2009;21:373-86.

8) Fattori R, Cao P, De Rango P, Czerny M, Evangelista A, Nienaber C, et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol 2013;61:1661-78.