The importance of clinical and radiological follow-up after conservative treatment of iatrogenic type A aortic dissection: A case report

Abstract

Background:Iatrogenic type A dissections can be managed conservatively, but clear guidelines for treatment are lacking. Case presentation: This case illustrates a borderline situation that necessitated a change in treatment approach. A patient underwent endo-prosthetic treatment for an aneurysm. During the insertion of a guiding catheter through the axillary artery, the ascending aorta was dissected, with contrast injected into the vascular wall. Due to the mechanism of injury and the absence of an intra-aortic intimal tear (as evidenced by contrast stagnation in the false lumen), conservative management was initially chosen. A follow-up computed tomography (CT) scan showed complete resolution after 1 month. However, 10 days later, the patient was readmitted with acute chest pain, and a new CT scan revealed an acute dissection, with a free-moving intimal flap in the ascending aorta, requiring emergency surgery. Current guidelines recommend surgery for iatrogenic type A dissections that extend or propagate several centimeters into the ascending aorta. However, these guidelines do not account for the mechanism of injury, the localization, or the size of the intimal tear. Conclusion: In this case, the assumption of spontaneous healing with an intact intima was initially supported. However, further developments highlight the importance of clinical and radiological follow-up, regardless of the injury’s mechanism. Relevance for patients: Iatrogenic aortic dissection is a highly complex condition that requires close monitoring and, if necessary, a reassessment of the chosen treatment strategy.

Keywords

Intravascular catheterization / Intimal tear / Iatrogenic type A aortic dissection / Mechanism of injury / Conservative management / Clinical follow-up / Radiological follow-up / Treatment guidelines

Funding

None.

Conflict of interest

The authors declare that they have no competing interests.

References

[1] Biancari M, Pettinari M, Mariscalco G, et al. Outcome after surgery in iatrogenic acute type A aortic dissection. J Clin Med. 2022;11:6729. doi: 10.3390/jcm11226729

[2] Nunez-Gil I, Bautista D, Cerrato E, et al. Incidence, management, and immediate- and long-term outcomes after iatrogenic aortic dissection during diagnostic or interventional coronary procedures. Circulation. 2015; 131:2114-2119. doi: 10.1161/CIRCULATIONAHA.115.015334

[3] Safdar A, Young L, Khatri J. Management of iatrogenic aortic dissection after percutaneous intervention of chronic total occlusion. Catheter Cardiovasc Interv. 2024; 104:1442-1446. doi: 10.1002/ccd.31262

[4] Elefteriades JA, Zafar MA, Ziganshin BA. Iatrogenic aortic dissection: Review of the literature. Aorta (Stamford). 2016; 4:240-243. doi: 10.12945/j.aorta.2016.16.067

[5] Ramasamy A, Bajaj R, Jones DA, et al. Iatrogenic catheter-induced ostial coronary artery dissections: Prevalence, management, and mortality from a cohort of 55,968 patients over 10 years. Catheter Cardiovasc Interv. 2021; 98:649-55. doi: 10.1002/ccd.29382

[6] Piffaretti G, Mariscalco G, Tozzi M, Bruno VD, Sala A, Castelli P. Acute iatrogenic type A aortic dissection following thoracic aortic endografting. J Vasc Surg. 2010; 51:993-9. doi: 10.1016/j.jvs.2009.10.105

[7] Wolfers MP, Yu Q, Montorfano L, Bordes SJ, King T. Type A thoracic aortic dissection following endovascular repair of a common iliac artery aneurysm. Cureus. 2021; 13(3):e13971. doi: 10.7759/cureus.13971

[8] Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35:2873-926. doi: 10.1093/eurheartj/ehu281