aortic dissection following coronary angiography and angioplasty is a rare , but potentially fatal complication with an overall reported incidence of 0.01 - 0.04% [ 1 - 3 ] .
the incidence is significantly higher during percutaneous coronary interventions ( 0.12% ) than during elective diagnostic procedures .
moreover , in the setting of acute myocardial infarction ( ami ) , the reported incidence is 0.19% , significantly higher than the 0.01% reported in the absence of ami .
management and outcomes have varied considerably in the literature . while up to 50% mortality was reported in one series following surgical repair of the dissections , other studies reported more favorable outcomes with conservative management .
we report a case of an elderly woman who developed type a aortic dissection with moderate to severe aortic regurgitation and heart failure , diagnosed approximately 1 month following a diagnostic coronary angiography .
she underwent emergency surgical repair of the dissection ; however , she could not be successfully weaned off of cardiopulmonary bypass despite maximum pharmacological interventions and support and died in the operating room .
a 63-year - old white female with known hypertension , hyperlipidemia , and prior pacemaker insertion for atrial fibrillation with symptomatic bradycardia , was admitted to our hospital with recent onset substernal chest pressure radiating to her jaw , with diaphoresis .
her vital signs were stable , and her physical examination was non - revealing , but was limited by her morbid obesity .
her electrocardiogram revealed atrial fibrillation with demand ventricular pacing and her cardiac biomarkers were negative for acute coronary syndrome .
echocardiogram revealed normal left ventricular systolic function and normal aortic root diameter , otherwise was technically difficult ( fig .
coronary angiography revealed 60 - 70% eccentric lesion in the second obtuse marginal , otherwise mild atherosclerotic disease .
( a ) baseline two - dimensional ( 2d ) parasternal long axis echocardiographic image obtained prior to index cardiac catheterization showing normal size aortic root and ascending aorta ( ao ) . ( b ) corresponding 2d parasternal echocardiographic image 1 month following cardiac catheterization showing massive dilatation of the aortic root and ascending aorta ( ao ) with a dissection flap .
lv : left ventricle ; rv : right ventricle ; la : left atrium .  
she was readmitted 1 month later with recurring episodes of chest pain , shortness of breath , orthopnea and reduced exercise tolerance which started ever since her recent discharge , for which she had two emergency room visits and a clinic follow - up visit .
blood pressure ( bp ) was 152/93 mm hg , and heart rate was 105 bpm .
she had an elevated bnp of 1,400 pg / ml , but otherwise negative cardiac biomarkers , and was therefore treated with diuretics , which resulted in a significant decrease of her bp to 81/51 mm hg .
repeat echocardiogram was performed , which revealed normal left ventricular systolic function , and severely dilated aortic root , measuring 6.7 cm , with aortic dissection flap noted ( fig .
ct angiogram revealed aortic dissection extending proximally to the aortic root above the coronary ostia ( fig .
( a ) axial ct angiographic image showing the dissection starting at the aortic root and sparing the origins of the coronary arteries , with massive dilatation of the aortic root .
( b ) sagittal ct angiographic image showing the extension of the dissection to the origin of the brachiocephalic artery .  
the patient was taken emergently to surgery and despite extensive surgical repair and pharmacologic support , she could not be weaned off of cardiopulmonary bypass and expired in the operating room .
type a aortic dissection is a lethal condition with an overall surgical mortality of up to 34% in unstable patients , as reported   in 526 cases by the international registry of acute aortic dissection ( irad ) .
the irad registry reported 28 cases ( 5.3% ) of iatrogenic type a aortic dissection ( itaad ) as a complication of cardiac surgery or cardiac catheterization , nine of which ( 32% ) died .
the german registry for acute aortic dissection type a ( geraada ) reported a comparable incidence of 100 cases ( 4.7% ) of itaad out of a total of 2,137 cases of type a aortic dissection , but with a lower 30-day mortality of 16% .
leontyev et al   reported 48 cases over a 15-year follow - up , undergoing surgery for itaad , with a frequency of 0.06% ( 36 cases ) of open heart surgeries , and 0.01% ( 12 cases ) of cardiac catheterizations ; early surgical mortality was 50% for itaads associated with coronary angiography . dunning et
al   reported nine cases ( 0.02% ) of coronary artery - aortic dissections out of over 40,000 cardiac catheterizations performed over a 6-year period ; these were significantly more prevalent in the setting of ami ( 0.19% ) , compared with non - ami ( 0.01% ) . while outcomes were favorable for the less severe dissections treated conservatively , two of the reported cases had dissection extending into the arch , and both died following surgery .
they proposed a classification scheme based on the extent of aortic dissection beyond the involved coronary cusp ( fig .
3 ) , and concluded that the best treatment in class 1 and 2 dissections is stenting of the intra - coronary entry point when possible and close clinical follow - up , while class 3 dissections usually require surgical intervention .
gomez - moreno et al   reported 17 cases ( 0.04% incidence ) of itaad associated with cardiac catheterizations over a 10-year follow - up period , with a significantly higher incidence after interventional procedures ( 0.12% ) than after diagnostic procedures ( 0.01% ) .
patients were treated conservatively with either stenting to seal the entry door or expectant management ; no patients died during hospitalization or follow - up .
nunez - gil et al   reported 14 cases ( 0.02% incidence ) of iatrogenic dissection of the descending aorta / arch without coronary involvement over a 15-year follow - up treated conservatively , with only one hospital death .
tanasie et al   reported eight cases over a 5-year follow - up of itaads referred for multi - detector coronary tomography ( mdct ) evaluation ; one patient required surgery and died , while all others treated conservatively with either stenting or expectant management survived . dunning classification of itaad .  
several cases of conservatively treated itaad have been reported in the literature with favorable outcomes .
sakakura et al   reported a 79-year - old male with itaad following stenting of proximal right coronary artery ( rca ) for angina who was treated with intravascular ultrasound ( ivus)-guided stenting of the entry point with good outcome .
fiddler et al   reported a 65-year - old female who underwent rca stenting for ami resulting in guidewire - associated itaad with evidence of tamponade ; there was spontaneous hemodynamic stabilization and subsequent ct demonstrating no intimal dissection flap , prompting expectant management with favorable outcome .
kerut et al   reported a 79-year - old male undergoing coronary angiography for angina , who developed subintimal hematoma , without dissection flap , in the left coronary sinus and 4 cm upwards as demonstrated by ct and transesophageal echocardiography ( tee ) ; these findings resolved spontaneously and she was treated conservatively with favorable outcome .
ghaffari and pourafkari   reported itaad proximal to the origin of the right brachiocephalic artery in a 30-year - old male with bicuspid aortic valve undergoing aortography in preparation for aortic coarctation stenting .
the dissection spontaneously sealed , and they attributed this to curved catheter position in the aortic arch and high - pressure contrast jet through the catheter side holes in the setting of aortopathy .
gorog et al   reported a 56-year - old female undergoing coronary angiography who developed aortic dissection starting at the femoral artery extending into the aortic arch , treated successfully with a self expanding metallic stent into the iliac artery via the contralateral femoral artery approach .
shah et al   reported two cases of itaad , the first was a 56-year - old male receiving rca stent for inferior ami who developed itaad starting at the rca cusp , successfully treated with stenting of the proximal rca to cover the entry point .
the second case was a 68-year - old male who developed left main coronary dissection with retrograde extension into the coronary cusp during stenting of the left circumflex , treated successfully with left main stenting ; he subsequently underwent an uneventful elective coronary artery bypass grafting ( cabg ) surgery .
welch et al   reported a 65-year - old female treated with multiple rca stents for inferior ami who developed an 
intramural hematoma  extending from the right sinus of valsalva to the origin of the brachiocephalic artery , with an entry point .
lambelin et al   reported a 75-year - old female who developed cardiac tamponade and cardiogenic shock due to intimal tear in the ascending thoracic aorta , not involving the coronaries , during angiography for aortic insufficiency ; she was successfully treated with immediate surgery .
noguchi et al   reported a 66-year - old male with inferior ami undergoing circumflex stenting , who developed cardiac tamponade and hypotension due to itaad originating at the brachiocephalic artery , without involvement of the coronaries ; he underwent successful emergency surgical repair .
yilik et al   reported two cases of itaad treated surgically , the first was a 65-year - old female who developed retrograde aortic dissection during angioplasty of the left anterior descending ( lad ) for unstable angina ; due to inability to localize the tear , she underwent uneventful surgical repair .
the second case was a 73-year - old female who developed itaad during angioplasty to the rca , the guidewire could not be introduced into the true lumen and therefore she underwent successful surgical repair .
tochii et al   reported a 69-year - old male who developed aortic dissection during balloon angioplasty to the left subclavian which extended retrogradely to the ascending aorta and required surgical intervention with good outcome .
the above case reports , summarized in table 1 [ 8 - 18 ] , demonstrate the heterogeneity of itaad with regard to patient characteristics and presentations , cause and location of the dissection , and treatment options .
it is obvious that severe dissections are associated with high early mortality and therefore warrant emergency surgery , which in itself carries very high risk of mortality .
our patient is unique in that her presentation was delayed at 1 month from her index cardiac catheterization , with progressive symptoms , likely causing extensive aortic root dilatation and extension of dissection ( dunning class iii ) .
negative outcomes may in fact be more prevalent than our discussion implies , but may tend to be under - reported in the literature .
associated risk factors reported in several studies may be related to patient characteristics versus procedural variables , some of which may be modifiable ( table 2 ) .
prompt recognition and management is crucial to avoid the extensive dissection and dilatation of the aorta , as we report in our patient , and reduce mortality .
low risk dissections appear to respond well to conservative medical and localized interventional treatments , with serial hemodynamic monitoring , imaging and follow - up .
high risk dissections overall appear to require surgical management , despite the increased surgical risk .
associated risk factors reported in several studies may be related to patient characteristics versus procedural variables , some of which may be modifiable ( table 2 ) .
prompt recognition and management is crucial to avoid the extensive dissection and dilatation of the aorta , as we report in our patient , and reduce mortality .
low risk dissections appear to respond well to conservative medical and localized interventional treatments , with serial hemodynamic monitoring , imaging and follow - up .
high risk dissections overall appear to require surgical management , despite the increased surgical risk .
 we report a 63-year - old female with hypertension , hyperlipidemia , and prior pacemaker insertion for atrial fibrillation with symptomatic bradycardia , who was admitted with substernal chest pressure and diaphoresis . 
 her electrocardiogram revealed atrial fibrillation with demand ventricular pacing and her cardiac biomarkers were negative for acute coronary syndrome . 
 echocardiogram revealed normal left ventricular systolic function and normal aortic root diameter . 
 coronary angiography revealed 60 - 70% obtuse marginal lesion , otherwise mild disease . 
 she was treated medically and discharged in stable condition . 
 she was readmitted 1 month later with recurring chest pain , and shortness of breath which started shortly after her most recent discharge . 
 blood pressure was 152/93 mm hg , and heart rate was 105 bpm . 
 bnp was elevated at 1,400 pg / ml , and other cardiac biomarkers were negative . 
 she was treated with diuretics , which resulted in decrease of her blood pressure to 81/51 mm hg . 
 repeat echocardiogram revealed severely dilated aortic root , measuring 6.7 cm , with aortic dissection flap and moderate to severe aortic regurgitation . 
 ct angiogram revealed aortic dissection extending proximally to the aortic root above the coronary ostia and distally to the left subclavian artery takeoff . 
 she underwent surgery ; she , however , could not be weaned off from cardiopulmonary bypass and died in the operating room . 
 this case illustrates the importance of having a high index of suspicion for iatrogenic aortic dissection following cardiac catheterization as a cause of recurrence of cardiac symptoms , as early detection may help avert a catastrophic outcome , as we report in our patient . 
Introduction
Case Report
Discussion
Conclusion
Disclosures