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A 42 year old man was referred for investigation of an abnormal chest x ray that showed profound widening of the mediastinum suggestive of a large thoracic aneurysm. At the age of 35 years he had collapsed while at work. At the time no specific cause had been found. He was otherwise fit and well. Thoracic computed tomography had showed dilatation of the aorta extending from the arch to the level of the renal arteries but did not confirm dissection. Transthoracic echocardiography had suggested an intimal flap within the descending aorta. Transoesophageal echocardiography was not routinely available at that time.

The image shows a contrast angiogram of the descending aorta revealing extensive dissection with compression of the true lumen by a large false lumen. The true lumen communicates with the false lumen through a number of stripped off intercostal arteries giving a series of jets akin to those seen when using a steam iron.

Following discussion with cardiothoracic surgeons it was decided to treat the patient conservatively.