Catastrophic STS/SVS type B3 aortic dissection complicated by hepatic portal venous gas and multi-organ malperfusion: a case report.

BACKGROUND

Acute aortic dissection (AAD) complicated by visceral malperfusion represents a catastrophic vascular emergency associated with high mortality. The coexistence of hepatic portal venous gas (HPVG) in this setting is an ominous radiological sign, typically indicating irreversible transmural bowel necrosis and breach of the mucosal barrier. We report a fatal case of STS/SVS Type B3 aortic dissection presenting with extensive visceral ischemia and HPVG to highlight the diagnostic significance of this "deadly triad."

CASE PRESENTATION: A 64-year-old male with a history of hypertension presented to the emergency department with severe, unremitting abdominal pain of 8 h' duration. Physical examination revealed significant four-limb blood pressure asymmetry, with a systolic gradient of nearly 100 mmHg between the right and left upper limbs, alongside diffuse abdominal tenderness. Computed tomography angiography (CTA) demonstrated an STS/SVS Type B3 aortic dissection extending from the aortic arch to the iliac arteries. Critical findings included the celiac trunk and superior mesenteric artery (SMA) straddled the dissection flap, representing a typical combination of static and dynamic obstruction. Critical findings included diffuse HPVG, pneumatosis intestinalis, and multi-organ ischemia. Laboratory results showed admission leukocytosis (WBC 27.1 × 109/L) and a massive cytokine storm (IL-6: 14,001.98 pg./mL) with refractory lactic acidosis. Due to the grave prognosis, the family opted for palliative care, and the patient expired 47 h after the decision.

CONCLUSION

This case underscores the rapid clinical deterioration associated with STS/SVS Type B3 dissection and complex visceral malperfusion. Early CTA recognition of HPVG is vital for identifying irreversible intestinal damage and informing multidisciplinary decision-making in devastating vascular emergencies.