Acute Aortic Dissection Associated With Cancer Therapy in a Previously Normal Aorta

BACKGROUND: Prophylactic management for aortic dissection, a life-threatening emergency, is traditionally guided by aortic diameter. CASE SUMMARY: A 60-year-old man, on pembrolizumab and lenvatinib for recurrent clear cell renal cell carcinoma, presented with chest pain, hypotension, and bradycardia during pembrolizumab infusion. Despite previously normal aortic dimensions on sequential imaging, computed tomography aortography revealed Stanford type A dissection requiring urgent surgery. DISCUSSION: This case supports emerging evidence for an association between acute aortic syndromes and modern cancer therapies, even in patients without structural warning signs. The potential for acquired aortic wall disease without associated dilatation cautions against risk stratification based only on aortic dimensions. TAKE-HOME MESSAGES: Cancer therapy-related vascular toxicity may predispose to acute aortic syndromes through acquired aortic wall vulnerability, even in the absence of prior aortic dilatation. This highlights the limitations of diameter-based risk stratification and the need for vigilant clinical assessment and strict blood pressure control.