Aortic dissection

A 75-year-old male patient returned for evaluation of high-risk multiple myeloma (17p deletion and 1p deletion).1 He had a history of diffuse large B cell non-Hodgkin lymphoma that had been treated with R-CHOP as well as Zevalin on a clinical trial protocol in 2007. Eight years later, he was diagnosed with multiple myeloma and he was treated with four cycles of cyclophosphamide, bortezomib and dexamethasone (CyBorD) followed by an autologous stem cell transplant after high-dose melphalan conditioning chemotherapy. Unfortunately, he had evidence of disease progression 60 days after his autologous stem cell transplant and therapy with carfilzomib, lenalidomide and dexamethasone was recommended.2,3 He responded to therapy with improvement in his functional state. He went deer hunting and while climbing some steps, noticed the development of a tearing sensation in the lower abdomen. He stopped to rest and when he resumed walking, the pain extended into his buttocks and radiated to the right leg. The symptoms resolved completely and he returned for evaluation at Mayo Clinic 3 months after this episode. He denied any pain or claudication. His blood pressure was 122/65 mm Hg with a pulse of 66 beats per minute. His radial pulses were normal but his right dorsalis pedis and posterior tibialis pulses were reduced compared to the left. There was no murmur or bruit on auscultation. His hemoglobin was 9.9 g/dl (11.5 g/dl during his prior visit), his creatinine was 1.4 mg/dl compared to 1.1 mg/dl 3 months prior. There was biochemical and radiologic evidence of myeloma progression with a 0.5 g/dl increase in the serum monoclonal protein. Due to a suspected diagnosis of aortic dissection, a CT angiogram of the chest, abdomen and pelvis was obtained. Imaging (Figure 1A-B), showed a type B dissection starting distal to the left subclavian artery and involving the whole abdominal aorta and continuing down the right common and external iliac arteries to the level of the femoral artery. Flaps extended into the celiac and superior mesenteric arteries as well. The dissection did not appear acute and there was no evidence of a pleural effusion, inflammatory reaction or solid organ or gut ischemia. He was seen by a vascular medicine consultant and vascular surgery and advised to avoid strenuous exercise and keep the blood pressure under control with repeat imaging planned for 3 months. He was started on daratumumab, pomalidomide and dexamethasone4 but unfortunately died of progressive multiple myeloma 2 months later.