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Vol. 68. Issue 3.
Pages 254-255 (March 2015)
Scientific letter
DOI: 10.1016/j.rec.2014.09.016
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Type A Iatrogenic Aortic Dissection Following Catheterization Without Coronary Involvement: Long-term Prognosis
Disección iatrogénica de aorta por catéter tipo A, sin afectar a la coronaria: estudio pronóstico a largo plazo
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Iván J. Núñez-Gil
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ibnsky@yahoo.es

Corresponding author:
, Daniel Bautista, María José Pérez-Vizcaíno, Enrico Cerrato, Pablo Salinas, Antonio Fernández-Ortiz
Unidad de Cardiología Intervencionista, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
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Table. Individualized Summary for Each of the Patients
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To the Editor,

Type A aortic dissection involves high mortality and typically requires surgery. Although it is usually spontaneous, cases have been observed after surgical procedures and, less frequently, interventional procedures.1-3 Due to its low frequency (< 0.1%), there are few data on this topic.1 In 2002, the International Registry of Acute Aortic Dissection (IRAD) reported 26 cases (69% postoperative and 27% due to catheterization) out of a total of 723.1 The epidemiology varied when compared with spontaneous presentations: those with iatrogenic aortic dissection were older, were more frequently diabetic or hypertensive, and had a greater degree of atherosclerosis, or a history of coronary bypass. Symptoms also varied: patients with iatrogenic dissection had less back pain or, when present, it had different characteristics, a higher frequency of hypotension and shock, and a high probability of ischemia and myocardial infarction (36% and 15%, respectively).

Although the prognosis of iatrogenic presentations was associated with high mortality in the past,1 recent registries, such as the German GERAADA, indicate a mortality rate that is similar to spontaneous dissection.2

Our objective was to analyze the incidence, characteristics, and prognosis of iatrogenic aortic dissection following catheterization.

Between October 2000 and July 2014, we performed 58 518 procedures, 36 372 of which were diagnostic and the remaining 22 146 were therapeutic. We identified 14 patients with dissection of the descending aorta/arch, without coronary dissection. The incidence was 0.02%, with a mean age of 68.5 years and a predominance of men (Table). The main reason for catheterization was chest pain along with acute coronary syndrome (10 cases). Five patients were treated urgently, 3 of whom had ST elevation. In 4 patients, the procedure was exclusively diagnostic, while 7 patients underwent successful coronary intervention. Guiding catheters were used in 10 patients, but the intervention had to be postponed due to the dissection. The approaches used were as follows: right femoral artery in 9 patients (64.3%), left radial in 4, and right radial in 1. All the radial approaches were performed from 2011 onward. The average contrast amount was 241 mL, fluoroscopy time was 26.3 minutes, and total time was 89.3 minutes. Presentation was acute in all patients and coincided with the catheterization of a vessel in 10 patients. In general, dissection occurred with 6-Fr catheters (Amplatz in 6 patients, extrabackup in 3, and Judkins in 3) and 2 with the 0.35″ guide. Twelve patients received acetylsalicylic acid, 4 in conjunction with clopidogrel, and 1 in addition to fibrinolysis with tenecteplase. All patients received anticoagulants during the procedure.

Table.

Individualized Summary for Each of the Patients

Case  Sex  Age, y  CVRF  Predisposing condition/aortopathy  Reason for catheterization  Type/access/indicationa  Cause/moment of dissectionb  Type/dissection locationc  Year/outcome 
Male  74  HTN, smoker  Abnormal RC  NSTEACS  Elective/right femoral/therapeutic  RC catheterization/AL2  1, right sinus  2009/good 
Male  67  DLP  No  STEACS  Urgent/right femoral/therapeutic  Trunk catheterization/AL3  3, ascending and descending aorta  2003/exitus 
Male  61  DLP, smoker  No  Unstable angina  Elective/left radial/diagnostic  Moving 0.35 guide forward by subclavian  Unclassifiable/aortic arch  2011/good 
Male  65  HTN, DLP, smoker  No  NSTEACS  Elective/left radial/therapeutic  RC catheterization/AR1  1, right sinus  2013/good 
Male  73  HTN, DLP, DM, smoker  No  NSTEACS  Urgent/right femoral/therapeutic  Trunk catheterization/XB3.5  3, ascending aorta  2010/good 
Male  71  DLP, smoker  No  Stable angina  Elective/right radial/therapeutic  PTCA in RC/JL4 diagnostic  1, right sinus  2014/good 
Male  56  HTN, DLP, smoker  No  NSTEACS  Urgent/left radial/therapeutic  RC catheterization/JR4  1, right sinus  2013/good 
Male  71  HTN, DLP, DM, smoker  Infrarenal aortic aneurysm  NSTEACS  Elective/right femoral/therapeutic  Trunk catheterization/XB3.5  1, left sinus  2008/good 
Male  76  DLP, DM  No  STEACS  Urgent/right femoral/diagnostic  Trunk catheterization/AL2  1, left sinus  2006/good 
10  Female  77  HTN, DLP  No  STEACS  Urgent/right femoral/therapeutic  Moving balloon forward in RC/JR4 guide  1 right sinus  2005/good 
11  Male  59  HTN, smoker  No  NSTEACS  Elective/right femoral/diagnostic  Moving 0.35 guide forward  3, arch and descending  2004/good 
12  Female  67  HTN, DLP  No  Unstable angina  Elective/right femoral/therapeutic  RC catheterization/AL2  3, right sinus  2003/good 
13  Female  61  HTN, DLP  No  Valve study  Elective/right femoral/diagnostic  RC catheterization/AL2  1, right sinus  2002/good 
14  Female  82  HTN  No  Stable angina  Elective/left radial/therapeutic  Trunk catheterization/XB3.5  1, left sinus  2012/good 

PTCA, percutaneous angioplasty; AL, Amplatz catheter, left coronary; AR, Amplatz catheter, right coronary; RC, right coronary; DLP, dyslipidemia; DM, diabetes mellitus; CVRF, cardiovascular risk factors; HTN, hypertension; JL, Judkins catheter, left coronary; JR, Judkins catheter, right coronary; STEACS, ST-elevation acute coronary syndrome; NSTEACS, non-ST-elevation acute coronary syndrome; XB, extra-backup catheter (“high support” for left coronary; all are guides).

a

Therapeutic: when guide catheters were used to perform interventionism, whether completed or not.

b

In therapeutic catheterization, the catheter used is a guide, except when otherwise indicated.

c

The number indicates the type according to the Dunning et al classification.3

During a mean follow-up of 62.4 months, there was 1 hospital death. None of the other patients who had been treated conservatively developed complications secondary to dissection, progression, ischemia, pain, or recurrence (Table).

There are few data on this complication, and published articles are limited to small case series or case reports. In addition, most include dissections of the ascending aorta and those occurring after dissection in a coronary artery.3,4 Here, we have excluded this type because the access port is different. In the coronary arteries, conservative management has been described with good results if the vessel continues to have good flow and the dissection is small4; if not, implanting a stent at this point would seal the flap and would generally resolve the problem satisfactorily.3,4 In 2002, Dunning et al3 published a series of 9 patients with coronary dissection extending to the aorta (incidence, 0.02%) and proposed a classification in 3 grades: type 1, dissection limited to the sinuses of Valsalva; type 2, dissection of the ascending aorta outside of the sinuses < 4 cm; and type 3, dissection ≥ 4 cm. These authors proposed that stent implantation was sufficient in the limited forms, but those with type 3 required surgery.3

Our series is different since coronary intervention does not resolve the complication. Furthermore, indicating complex surgery of the ascending aorta could be catastrophic in patients who are often under the effects of intense antithrombotic treatment and have had a recent myocardial infarction.1–4 It is therefore a relevant complication considering the volume of procedures performed in our setting.5

After following-up, our patients for more than 5 years on average, we have seen excellent outcomes, regardless of the access used (radial or femoral), even though many continued to receive intense antithrombotic treatment when their condition was acute. The profile of the patients affected with this complication is that of a male in his sixties, with cardiovascular risk factors (mainly atherosclerotic-ischemic), who undergoes a complex procedure (generally therapeutic) with difficult coronary catheterization.

Based on this information, we can conclude that if there are no important symptoms, the dissection is small and the imaging studies show no progression (Figure), it seems reasonable to follow a conservative strategy. If not, surgery may need to be considered.

Figure.

Patient number 5 (Table). Arrow: Dissection; A: Acute moment, which required cessation of the procedure; B: 3 days later, aortogram showing definite improvement; at that time, angioplasty was done in the anterior descending artery without complications; C: Tomography showing the initial hematoma/thrombotic dissection at the ascending aorta (A); D: Follow-up tomography 9 months later (at the same height of C) showing complete symptom resolution.

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References
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Iatrogenic aortic dissection.
Am J Cardiol., 89 (2002), pp. 623-626
[2]
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Iatrogenic acute aortic dissection type A: insight from the German Registry for Acute Aortic Dissection Type A (GERAADA).
Eur J Cardiothorac Surg., 44 (2013), pp. 353-359
[3]
D.W. Dunning, J.K. Kahn, E.T. Hawkins, W.W. O’Neill.
Iatrogenic coronary artery dissections extending into and involving the aortic root.
Catheter Cardiovasc Interv., 51 (2000), pp. 387-393
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S. Gomez-Moreno, M. Sabaté, P. Jimenez-Quevedo, P. Vazquez, A. Alfonso, R. Hernández Antolín, et al.
Iatrogenic disecction of the ascending aorta following heart catheterization: incidence, management and outcome.
Eurointervention., 2 (2006), pp. 197-202
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B. García del Blanco, J.R. Rumoroso Cuevas, F. Hernández Hernández, Trillo Nouche.
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Rev Esp Cardiol., 66 (2013), pp. 894-904
Copyright © 2014. Sociedad Española de Cardiología
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