Every disease is associated with misdiagnosis and diagnostic delay with significant variances of frequency and interval until reaching the correct diagnosis [5]. In the setting of the emergency department, aortic dissection is rare, and misdiagnosis and DD of aortic dissection are common, occurring in 14.1–39.4% of TAAAD patients [6] and are associated with worse outcomes [7]. In IRAD, DD was reported to be associated with a history of previous cardiac surgery, presentation without abrupt or any pain, and initial presentation to a nontertiary care hospital [8].

The diagnosis of TAAAD can be made by transthoracic or transesophageal echocardiography, CT, or magnetic resonance imaging (MRI). Although the transthoracic echocardiography is very useful in diagnosing aortic regurgitation, pericardial tamponade and cardiac wall motion abnormalities associated with coronary malperfusion caused by TAAAD, the value of transthoracic echocardiography is limited in patients with abnormal chest wall configuration, narrow intercostal spaces, obesity, pulmonary emphysema, and in patients on mechanical ventilation [9]. The transesophageal echocardiography is highly accurate for the detection of TAAAD; however it requires esophageal intubation, thus highly invasive. MRI is highly accurate imaging modality with a sensitivity of 95–98% and specificity of 94–98% for detecting aortic dissection [10]. However, its use in the emergency setting is very limited because of the limited access and cost. Moreover, it is time-consuming. Therefore, CT scan with contrast material is of paramount use because of relatively good access, acceptable cost, and good diagnostic accuracy. Although most of the diagnosis of aortic dissection was made based on the images of CT scan with contrast material, and the diagnosis was more likely to be missed or delayed when patients presented with atypical symptoms and physicians were not willing to infuse contrast material for potential renal damage and radiation.

The visualization of an intimal flap is the characteristic feature of TAAAD. If there is flow within both lumina, typical imaging features are probably present in the images of CT scan with contrast material. If the false lumen is thrombosed or there is no intimal tear to permit flow through the false lumen, a visible intimal flap may not be present. Secondary signs of TAAAD include an intramural or periaortic acute thrombus, which manifests as a high-attenuation cuff or crescent on the images of CT scan without contrast material as in our case 1. Other conditions that can reduce the diagnostic accuracy of the intimal flap include atypical configurations of the flap, such as seen with short dissections or with multiple false channels, in which the flaps are complex [11]. It is very important to pay attention to the small calcified masses, if any, located on the displaced flap, which renders physician accurate diagnosis of TAAAD with patent false lumen, even with CT scan without contrast material.

Every error in medical decision-making reportedly can be classified into three types: non-fault errors, system errors, and cognitive errors [12]. Non-fault errors include cases where the illness is silent, masked, or presented in such as an atypical fashion that divines the correct diagnosis. System errors reflect latent flaws in the health care system, including weak policies, poor coordination of care, inadequate training or supervision, defective communication, and the many system factors that detract from optimal working conditions such as stress, fatigue, and distraction. Cognitive errors are those in which the problem is inadequate knowledge faulty data gathering, inaccurate clinical reasoning, or faulty verification.

All the cases in this article were with diagnostic delay, not misdiagnosis. In our cases of diagnostic delay, every case has a component of non-fault error because the illness presentation is less severe compared with typical tearing pain of TAAAD or unstable hemodynamics. System error was more evident in case 1 where the radiology technician was almost confident about the presence of TAD, and poor communication between the radiology technician and doctors hampered the re-CT scan with contrast material or at least hospital admission for observation. The lack of knowledge of TAD with thrombosed false lumen is also attributable to system error as well. Case 3 was the case in which the definitive diagnostic step was delayed. According to the history the patient had given, the fact that he did not have health insurance might be a sufficient excuse for the physician not to take a CT scan during the emergency visit to the first hospital. Even in this circumstance, when the patient presented with severe back pain, the physician should have paid attention to the history of 4 cm ascending aorta dilatation since normal proximal ascending aorta was reported as 3.0 ± 0.4 cm [13].

Cognitive error was evident in case 2 in which the physician noticed the presence of aspiration pneumonia, but not the difference of contrast in the ascending aorta and size between ascending and descending aorta. This overlook might be influenced by the fact that the physician in charge was a part-time doctor and the timing of CT scan was the end of his working hour.

There might be several solutions to improve the diagnostic accuracy of TAAAD; careful medical examination including the characteristics of pain that patients experienced, improvement of communication within the medical team, timely and adequate education and training of TAAAD management, mutual assisting system between full-time and part-time physician, and so on to reduce diagnostic errors. The use of aortic dissection detection risk score [14] and echocardiography [15, 16] might be helpful to prevent misdiagnosis and DD. Either way, every single step should be taken to reduce diagnostic errors to save the lives of patients with TAAAD.