Alfonso et al. report two cases of localized acute dissection of the ascending aorta complicating coronary angioplasty. After sealing the entry door, both patients were managed conservatively and discharged uneventfully.
The true incidence of this complication of coronary angiography and angioplasty is unknown. There is a natural tendency to publish terapeuthic success, but not iatrogenic complications. Furthermore, in an effort to minimize the risk of being sued for malpractice as often happens in many nations, health care professionals endeavor to enhance a good patient-physician relationship and be as discreet as possible. This is a good reason not to publish iatrogenic cases, and also a good reason to applaud authors who do so .
Acute aortic dissection during attempted coronary angioplasty is so dramatic that it usually persists in one's memory. Since we have had two unpublished cases (attempting to dilate a right coronary artery, successfully treated with surgery), I asked five experienced interventional cardiologists in Argentina-Hugo Londero, Jorge Belardi, Luis de la Fuente, Jorge Leguizamon, and Alfredo Rodriguez-whether they have had a similar complication in their clinical practice. The pooled experience roughly approximates 21,000 coronary angioplasties, with four acute aortic dissections, two of them requiring surgical repair.
What can we learn from this and other reports of iatrogenic aortic dissections?
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There seem to be two different responses to the iatrogenic injury: a) a self-limited dissection to a few centimeters beyond the aortic valve, and b) a very different situation in which the dissection involves the ascending aorta and can also extend to the descending aorta. In such cases, the aortic dissection is probably due to an inherently weakened aorta caused by cystic medial necrosis, as confirmed by the case reported by Pande et al. .
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The exact mechanism responsible for aortic dissection during percutaneous coronary angioplasty remains to be established, but in