Aortography

Although largely superseded by transesophageal echocardiography and MRI, aortography remains useful in defining the proximal anatomy of a dissection found on CT scanning and should be considered if clinical suspicion of dissection is high but other investigations have been equivocal. It may require the use of upper limb arterial access to allow entry to the aorta. There is a risk of rupture of the weakened aorta during contrast injection. Although catheterization via the femoral artery will usually enter the true lumen, confirmation of catheter placement in the true lumen requires retrograde passage through the aortic valve. Aortography requires an experienced angiographer and the ability to obtain multiple angiographic projections. It is valuable in identifying involvement of branch vessels, demonstrating the intimal flap and unusual manifestations of dissection, for example rupture into the main pulmonary artery, the inferior vena cava, or a cardiac chamber. The most common cause of diagnostic error occurs when a tear has sealed over thrombosis of the false channel.

It is traditional practice to combine aortography with coronary arteriography. This is a procedure of questionable value. The procedure is technically difficult in a dissected aorta, is time consuming, and has a high false-negative rate. The vast majority of deaths following dissection of the ascending aorta are the result of aortic rupture, not coronary artery disease. The rationale for the procedure is that it allows assessment of the coronary arteries in a high-risk population who are about to undergo major cardiovascular surgery. Conversely, the diagnostic yield is low, and the procedure carries inherent risks and imposes extra delays before surgery during which time aortic rupture may occur.

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