eComment. Unusual presentation of acute aortic dissection.

Subacutely progressed tensive aortic dissection complicated with catheter-induced dissection in left main coronary artery. We read with great interest the report by Yazici et al [1]. The authors presented a case of a 66-year-old patient with bilateral anterior chest wall ecchymosis suffering from a subacute type A aortic dissection. The patient was successfully managed, and the postoperative course was uneventful. However, we believe that there are some issues that need to be addressed. Firstly, the authors stated that the intimal tear was located in the aortic arch. On the other hand in the discussion, they assumed that during coronary angiography the inappropriate engagement of the right coronary ostium with the guiding cath-eter was responsible for the aortic dissection. Iatrogenic aortic dissection in this setting would have been presented with an intimal tear in the vicinity of the coronary ostium. Secondly, they speculated that the extensive anterior chest wall ecchymosis in this patient was due to the extension of the dissection to both internal thoracic arteries. The precise mechanism accounting for the bilateral chest bruising remains to be demonstrated. Thirdly, ecchymosis in the suprasternal region in the context of acute aortic syndrome was previously depicted in two patients. Hashimi et al. [2] described a 72-year old female patient with progressive periaortic haematoma of the arch and descending aorta. Al-Hity et al. [3] presented a case of a 66-year old female patient with acute aortic dissection (DeBakey type III). These two patients presented with ecchymosis in the suprasternal region secondary to the leakage of blood from the pathologic aortic arch to the neck area. Although acute onset of severe chest or back pain is the most common presenting symptom, some patients may present with nonconforming symptoms and signs. There is a plethora of clinical presentation of this dreadful entity with varied symptomatology, including but not limited to syncope, headache, hemiparesis, atrial fibrillation, and superior vena cava syndrome [4]. Establishing a prompt diagnosis of aortic dissection can be difficult in the presence of atypical symptoms, especially in the absence of pain. We would like to thank Hajj-Chahine et al. for their eComment [1], which requires some explanations as follows: First of all, we recognized the intimal tear in the aortic arch in perioperative observation, but it was not the single source, there were multiple tears as it always occur. Nevertheless, all tissues were so inflamma-tory and fragile (subacute dissection) that finding a certain …