A Painless Thoracic Aortic Dissection

Thoracic aortic dissection (TAD) has a very high mortality rate and is often missed due to the atypical presentation of patients. We present a case of a man with chronic hypertension, atrial fibrillation (AF) (on regular warfarin) and a previous endovascular aneurysm repair (EVAR), who presented with dyspepsia and was incidentally found to have a ruptured distal thoracic aneurysm on imaging with no obvious clinical signs on examination, nor abnormalities on admission chest x-ray (CXR). LEARNING POINTS: Typical symptoms and signs of thoracic aortic dissection (TAD), such as sudden onset of tearing pain and difference in blood pressure, can be absent in patients. Clinicians should consider imaging of the aorta in high-risk patients who present with syncope, focal neurology and/or atypical chest, back or abdominal pain. There may be a role for D-dimer in the future to rule out the possibility of TAD, similar to pulmonary embolism (PE).