Localized Aortic Root Dissection Secondary to Contrast Agent Injection: Feasibility of Conservative Follow-up With Echocardiography

Ahmet Karabulut

doi:10.15171/hpr.2017.05

Abstract

Introduction: Iatrogenic aortocoronary dissection (ACD) is a nightmare in interventional cardiology. Although ACD is rarely reported, the real-world prevalence is suspected of being higher due to unreported cases. The right coronary artery (RCA) ostium is involved in the majority of cases, and dissections are usually limited to the aortic sinus in half of the clinical presentations. There are different treatment strategies, including interventional approaches, surgery, and medical follow-up. Immediate stent deployment to the coronary osteum might be a life-saving procedure, and the surgical approach should be preferred in occasions of dissection extension beyond the sino-tubular junctions. Catheter trauma and subintimal progression of guidewires are major causes of ACD occurrence.Case Presentation: Herein presented is a case report of spontaneous ACD observed after contrast injection to the RCA ostium. Approximately 8 cc of radiocontrast agent was injected into the right coronary ostium. Antegrade and retrograde dissections which extended to the distal RCA and aortic root were observed. The right sinus of Valsalva was stained with contrast agent, and the border of the stained area was extended to the sinotubular junction. Medical follow-up was proposed by the heart team. Close follow-up with echocardiographic examination indicated the complete regression of the dissection.Conclusion: The authors consider conservative follow-up with echocardiogaphy rather than computed tomography and/or magnetic resonance to be the most appropriate imaging technique for use with stable patients.

Highlights

Iatrogenic aortocoronary dissection (ACD) is a nightmare in interventional cardiology
The right coronary artery (RCA) ostium is involved in the majority of cases, and dissections are usually limited to the aortic sinus in half of clinical presentations
A case report of spontaneous ACD observed after contrast injection to the RCA ostium is reported

Summary

Introduction

Iatrogenic aortocoronary dissections (ACDs) are uncommon clinical entities. The majority of cases are catheter-induced. Spontaneous ACD secondary to contrast agent injection is rarely reported[1,2]; the real-world prevalance is expected to be higher because of unreported cases. Catheter trauma and subintimal progression of guidewires are major causes of ACD occurrence; isolated dissection secondary to radiocontrast injection is an extremely rare clinical entity.[2,3] The right coronary artery (RCA) ostium is involved in the majority of cases, and dissections are usually limited to the aortic sinus in half of clinical presentations. A case report of spontaneous ACD observed after contrast injection to the RCA ostium is reported . Antegrade and retrograde dissections which extended to the distal RCA and aortic root were observed (Figure 1). Computed tomography (CT) showed a localized 1.5 cm aortic root dissection originating from the RCA ostium and extending towards the sinotubular junction (Figure 2). Echocardiographic follow-up continued for the first month, and a three-month control follow-up was uneventful

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Discussion

Conclusion