Acute lower limb ischemia as an atypical manifestation of acute aortic syndrome

Acute aortic syndrome comprises a group of cardiovascular conditions associated with high morbidity and mortality, among which aortic dissection is particularly significant.Its prognosis depends on timely diagnosis and appropriate management.Although sudden, severe, tearing chest pain is considered the hallmark symptom, up to one-third of patients may present with atypical clinical manifestations, leading to diagnostic delays and increased mortality.We report the case of a patient with a history of chronic arterial hypertension, advanced chronic kidney disease, and active cocaine use, who presented without the classic symptoms of aortic dissection.The initial presentation consisted of severe pain and acute ischemia of the left lower limb, without chest or abdominal pain.Lower-limb computed tomography angiography revealed an intimal flap involving both common and external iliac arteries, associated with thrombosis of the left false lumen and limb malperfusion.Due to the patient's sudden and fatal clinical deterioration, further imaging characterization of the proximal extent of the dissection by thoracoabdominal computed tomography angiography or echocardiography could not be completed.This case highlights the importance of considering acute aortic syndrome in the differential diagnosis of high-risk patients, even in the absence of typical symptoms, to avoid delays in the management of a potentially fatal condition.