Late Diagnosis of a Large Extrapleural Hematoma in a Patient With Stanford Type B Aortic Dissection: A Case Report and Review of Literature.

Acute aortic dissection is a rare but catastrophic condition. When the dissection extends through the adventitia, blood can extravasate into the extrapleural or intrapleural spaces, causing an extrapleural hematoma or hemothorax. The early recognition of extrapleural hematoma and distinguishing it from hemothorax is critical because the management of those two entities is different. The authors present a case of a late diagnosis of a large extrapleural hematoma in a patient with Stanford type B acute aortic dissection that required thoracotomy for hematoma evacuation. The patient underwent successful thoracic endovascular aortic repair (TEVAR). Postoperatively, the patient had worsening pulmonary function, with a large fluid collection on imaging that was not drained by the thoracostomy tubes. Surgical exploration revealed a large extrapleural hematoma. Timely recognition of the extrapleural hematoma was key in the patient's clinical management. Without clear radiographic diagnostic features of extrapleural hematoma, unsuccessful drainage of hematoma after insertion of a chest tube may suggest an extrapleural hematoma or a clotted hemothorax. If patients continue to have circulatory or respiratory compromises, prompt surgical exploration should be considered. It is important for clinicians to be aware of extrapleural hematoma in complicated acute aortic dissection, especially when chest tube drainage of an apparent hemothorax is unsuccessful.