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Evaluating aortic dissection: when is coronary angiography indicated?
  1. Division of Cardiothoracic Surgery
  2. Department of Surgery
  3. Baylor College of Medicine
  4. 6560 Fannin, Suite 1100
  5. Houston, Texas 77030, USA
  6. email:

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Transoesophageal echocardiography (TOE), rapid sequence spiral computed tomography with intravenous contrast (CT), and magnetic resonance angiography (MRA) have become increasingly useful in the evaluation and diagnosis of acute dissection of the ascending aorta. These diagnostic modalities are fast, safe, non-invasive, and highly accurate, with sensitivity and specificity approaching 100%.1 And although most surgeons agree that aortography is no longer necessary before surgical intervention for acute aortic dissection, the role of coronary angiography remains controversial.

Clinical presentation

Acute dissection of the ascending aorta is a highly lethal event. Without surgical intervention, 50% of these patients die within the first 24 hours, 75% die within two weeks, and 90% die within one month.2 Most patients with acute aortic dissection present with sudden onset of severe chest pain that may migrate to the neck or back. Occlusion of aortic branch vessels may cause stroke, abdominal pain, or limb ischaemia. A history of hypertension, known thoracic aortic aneurysm, or characteristics of Marfan's syndrome should alert the physician to the possibility of aortic dissection. On arrival to the emergency room, these patients may appear pale, cool, or clammy, and hypertension is typically present. Hypotension or profound shock usually indicates a catastrophic complication, including pericardial tamponade, aortic rupture, coronary artery obstruction, or severe aortic regurgitation.

Diagnostic modalities

Echocardiography should be used as the initial diagnostic procedure in patients with suspected aortic dissection. Initially, a transthoracic echocardiogram (TTE) is performed. With this examination, the dissection can be identified and the tear site in the aorta may be located. Left ventricular function, aortic and mitral valve function, regional wall motion, and coronary artery involvement are also assessed. In …

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