Iatrogenic aortic dissection – Follow the image!

A 74-year-old woman with hypertension and dyslipidemia was referred to the cardiology outpatient clinic with dyspnea on moderate exertion. Physical examination was unremarkable. ECG had left ventricular hypertrophy voltage criteria. Transthoracic echocardiogram showed mild dilation of the left chambers and hypokinesia of inferior, posterior and lateral walls with mild depression of left ventricular systolic function. Because of the findings in the echocardiogram she was referred for invasive coronary angiography (CA) without an ischemia test. Left CA showed no coronary disease. After the first contrast injection in the right coronary artery (RCA)----which also excluded disease----a radiopaque area was seen in the aortic wall, suggesting catheter-induced (iatrogenic) ascending aortic dissection (IAD) (Figure 1, Panel A, arrow). A few minutes later, occlusion of RCA occurred as a result of dissection progression (Figure 1, Panel B, arrow). CT angiography (CTA) performed immediately in the hemodynamics laboratory (same room, moving gantry) confirmed IAD dissection and acute occlusion of the RCA (Figure 2A, B and C, arrows).