ABSTRACT
A 65-year-old man had acute Stanford type A aortic dissection complicated with upper extremity paralysis, 7 months after coronary artery bypass grafting. The superior mesenteric artery (SMA) appeared patent on CT angiography. However, color Doppler ultrasonography revealed malperfusion of the SMA. Progressive metabolic acidosis indicated bowel ischemia. Although antihypertensive therapy was selected due to possible injury of the right internal thoracic artery (RITA) graft at thoracotomy, revascularization of the SMA and reconstruction of axillary arteries were indicated due to increased paralysis and acidosis. Following anastomosis of a saphenous vein graft between the iliac artery and the SMA, the color and movement of the small intestine apparently improved. The axillary artery was transected and reconstructed with fenestration. Metabolic acidosis improved after SMA bypass but before superior axillary artery reconstruction. Upper extremity paralysis improved. Seven days later, however, he complained of sudden onset of back pain associated with hypotension, which was due to cardiac tamponade. He underwent replacement of the ascending aorta, elevation of the aortic valve, and reimplantation of the radial artery graft. He had an uneventful postoperative course and was discharged with no remaining complaints. In this case, treatment of upper extremity and bowel ischemia was selected prior to central operation, and irreversible damage was avoided. Color Doppler ultrasonography was helpful for diagnosing bowel ischemia before progression to necrosis. It must be remembered that patency diagnosed with CT angiography does not necessarily rule out mesenteric ischemia.