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Aortic dissection
Aortic Dissection A Complication
of Translumbar
Aortography
ARNOLDG. CORAN,M.D.ANDHENRY B. TYLER, M.D., West Roxbury, Massachusetts
From the Surgical Sernice of the West Roxbury Veterans Ltbst Roxbury, Massachusetts.
Administration Hospital,
INCE its introduction in 1929 by dos Santos, translumbar aortography has become a widely used diagnostic tool [l]. Some authors have reviewed their experience with this procedure indicating that aortography has been performed in several thousand cases without incident [1-d]. The earlier complications were of ten related to the contrast material used, such as sodium iodide and Diodrast@, both of which are quite toxic [5-71. Renal damage, retroperitoneal hemorrhage, and aortic dissection are the major untoward sequelae encountered; however, these complications are quite rare. Many other complications have been reported, such as spinal cord and intestinal damage, which are even rarer than the previously mentioned three [8]. Acute dissection of the abdominal aorta from translumbar angiography can prove to be a fatal complication unless recognized and properly treated. The angiographic picture of this event is quite distinct [9,10 1.We present a case illustrating the diagnosis and treatment of this complication. s
CASEREPORT
as follows: femoral, right l+ and left 3+ ; popliteal, right 0 and left 2+ ; posterior tibial, right 0 and left 0; dorsalis pedis, right l+ and left 3+. On the day after admission, the patient underwent translumbar aortography under local anesthesia. A No. 17 needle was used and there were two injections of 70 per cent Renografin@ into the aorta; one injection was 30 cc. and the second 40 cc. Before each injection, there was a free flow of blood into the needle. The patient experienced a small amount of back pain with the first injection. X-ray films (Fig. I) showed dense concentration of dye in the lower aorta with a sharp cutoff at the bifurcation; no collaterals were seen. After this procedure, the patient had no further pain and no change in the peripheral pulses. Since it was believed that this picture might represent an aortic dissection, it was elected to repeat aortography using the transfemoral retrograde approach. This film (Fig. 2) showed good filling of the aorta and its branch with a probable block in the right common iliac artery. On April 6 he underwent exploration of both iliac arteries, and at surgery dissection involving the right common iliac artery and aortic bifurcation was demonstrated. Endarterectomy of both common iliac arteries and the aortic bifurcation was performed, and both arteriotomy sites were sutured after the intima had been tacked down distally. Postoperatively, the patient did very well with the development of bounding peripheral pulses.
The patient (J.P.; WRVAH No. 01%16-4177), a forty-eight year old white man, entered the West Roxbury Veterans Administration Hospital on March 30, 1967 with a one year history of pain in the right thigh and calf on walking two to three blocks. The pain was also precipitated by climbing one flight of stairs. Claudication was always relieved by rest. Physical examination was unremarkable with the exception of the peripheral vascular system. Both legs were warm with no evidence of &hernia. There was a short bruit audible over the right femoral artery. The pulses in the legs were Vol. 115.May 1968
COMMENTS Dissection of the layers of the aorta seems to occur because the bevel of the needle lies partly within the lumen of the vessel and partly within the wall. Intramural injection then occurs from the applied pressure, especially with a diseased vessel. Usually only a small amount of dye is injected (about 1 cc.), and there are no sequelae. Occasionally, however, large amounts of contrast material are deposited intramurally; this 709
Coran and Tyler
710
A
B
FIG. 1. A, test injection of 7 cc. of 70 per cent Renografin. B, injection of 30 cc. of 70 per cent Renografin. In both films note the very dense concentration of dye, the very sharp cutoff of dye, and the absence of collateral vessels.
may cause occlusion of major aortic branches or produce a false extraluminal channel. A cardinal sign of an intramural injection is a sharply demarcated, persistent, dense collection of contrast medium. The column of contrast material equals or exceeds the diameter of the vessel injected. There may be no filling of the aortic branches if the injection is entirely intramural [11]. The sharp demarcation without the presence of collateral vessels is evidence of an intra-
FIG. 2. A transfemoral aortogram does not show any dissection. Note the stenosis in the right common iliac artery.
mural injection rather than of a complete aortic block, especially if femoral pulses are palpable. This sharp demarcation of abnormally dense dye is well demonstrated in Figure 1. Additional evidence of an intramural injection is often noted on the delayed roentgenograms. Here one sees the effects of occlusion of aortic branches (by either the intramural injection or the resultant dissecting aneurysm) if contrast medium enters the affected branch before occlusion occurs. The viscus supplied by the occluded branch is persistently opacified by contrast material trapped within it as a result of the loss of normal perfusion pressure. Although intramural injection of dye (usually less than 1 cc.) is seen in 10 per cent of lumbar aortograms, less than ten cases of aortic dissection secondary to translumbar aortography have been reported [8,9,11,12]. In many of these, no symptoms ever developed and recovery occurred without surgical intervention; some died of uremia from renal arterial occlusion, and some were successfully treated by arterial surgery. Only slight back pain developed in our patient during the occurrence of dissection and there was no pulse loss; however, the aortogram is diagnostic of dissection, which was proved at surgery. In this case, the radiographic appearance of the test injection of 7 cc. was characteristic of an intramural deposition of dye and should have alerted us to this occurrence with subsequent termination of the procedure at that point. Therefore, the test injection of a small volume of contrast material, in American
Journal of Surgery
Aortic
Dissection
addition to indicating whether a visceral vessel has been directly punctured, is helpful in demonstrating an intramural injection.
4. MCAFEE, J. G. A survey of complications
5. 6.
SUMMARY
A case of aortic dissection secondary to translumbar aortography is presented. The characteristic x-ray appearance of this event and the value of the test injection are emphasized. REFERENCES
1. CRAWFORD, E. S., BEALL, A. C., MOYER, J. H., and DEBAKEY, M. E. Complications of aortography. Surg. Gynec. 60 Obst., 104: 129, 1957. 2. BEALL, A. C., MORRIS, G. C., GARRETT, H. E., HENLEY, W. S., HALLMAN, G. L., CRAWFORD, E. S., COOLEY, D. A., and DEBAKEY, M. E. Translumbar aortography. Present indications and technics. Ann. Int. Med., 60: 843, 1964. 3. MCAFEE, J. G. and WILSON, J. K. I’. A review of the complications of translumbar aortography. Am. J. Roentgenol., 75: 956, 1956.
Vol. 115. May 1968
i.
8.
9.
10.
11.
12.
711
of abdominal aortography. Radiology, 68: 825, 1957. WAGNER, F. D. and PRICE, ,4. H. Fatality after abdominal arteriography. Surgery, 27: 621, 1950. AkNTONI, H. and LINDGRES, E. Steno’s experiment in man as complication in lumbar aortography. Acta chir. scandinazl., 98: 230, 1949. LARSON, II. and PALMLOV, A. Abdominal aortography with special reference to its complications. Acta radial., 38: 111, 1952. FINEBERG, C., SCHECHTER, D. C., and BARRICK, C. W. Gangrene of the large intestine and ovaries after translumbar aortography. J. A. 22f. A., 167: 1232, 1958. GAYLIS, H. and LAGS, J. W. Dissection of aorta as a complication of translumbar aortography. Brit. M. J., 2: 1141, 1956. GUDBJERG, C. E. and CHRISTENSEN,J. Dissection of the aortic wall in retrograde lumbar aortography. Acta radial., 55: 364, 1961. BOBLITT, D. E., FIGLEY, M. M., and WOLFMAN, E. F. Roentgen signs of contrast material dissection of aortic wall in direct aortography. Am. J. Roentgenol., 31: 826, 1959. SZILAGYI, D. E., SMITH, R. F., MACKSOOD, A. J., and EYLER, W. R. Abdominal aortography: its value and its hazards. .Ivch. Surg., 85: 25, 1962.
of Translumbar
Aortography
ARNOLDG. CORAN,M.D.ANDHENRY B. TYLER, M.D., West Roxbury, Massachusetts
From the Surgical Sernice of the West Roxbury Veterans Ltbst Roxbury, Massachusetts.
Administration Hospital,
INCE its introduction in 1929 by dos Santos, translumbar aortography has become a widely used diagnostic tool [l]. Some authors have reviewed their experience with this procedure indicating that aortography has been performed in several thousand cases without incident [1-d]. The earlier complications were of ten related to the contrast material used, such as sodium iodide and Diodrast@, both of which are quite toxic [5-71. Renal damage, retroperitoneal hemorrhage, and aortic dissection are the major untoward sequelae encountered; however, these complications are quite rare. Many other complications have been reported, such as spinal cord and intestinal damage, which are even rarer than the previously mentioned three [8]. Acute dissection of the abdominal aorta from translumbar angiography can prove to be a fatal complication unless recognized and properly treated. The angiographic picture of this event is quite distinct [9,10 1.We present a case illustrating the diagnosis and treatment of this complication. s
CASEREPORT
as follows: femoral, right l+ and left 3+ ; popliteal, right 0 and left 2+ ; posterior tibial, right 0 and left 0; dorsalis pedis, right l+ and left 3+. On the day after admission, the patient underwent translumbar aortography under local anesthesia. A No. 17 needle was used and there were two injections of 70 per cent Renografin@ into the aorta; one injection was 30 cc. and the second 40 cc. Before each injection, there was a free flow of blood into the needle. The patient experienced a small amount of back pain with the first injection. X-ray films (Fig. I) showed dense concentration of dye in the lower aorta with a sharp cutoff at the bifurcation; no collaterals were seen. After this procedure, the patient had no further pain and no change in the peripheral pulses. Since it was believed that this picture might represent an aortic dissection, it was elected to repeat aortography using the transfemoral retrograde approach. This film (Fig. 2) showed good filling of the aorta and its branch with a probable block in the right common iliac artery. On April 6 he underwent exploration of both iliac arteries, and at surgery dissection involving the right common iliac artery and aortic bifurcation was demonstrated. Endarterectomy of both common iliac arteries and the aortic bifurcation was performed, and both arteriotomy sites were sutured after the intima had been tacked down distally. Postoperatively, the patient did very well with the development of bounding peripheral pulses.
The patient (J.P.; WRVAH No. 01%16-4177), a forty-eight year old white man, entered the West Roxbury Veterans Administration Hospital on March 30, 1967 with a one year history of pain in the right thigh and calf on walking two to three blocks. The pain was also precipitated by climbing one flight of stairs. Claudication was always relieved by rest. Physical examination was unremarkable with the exception of the peripheral vascular system. Both legs were warm with no evidence of &hernia. There was a short bruit audible over the right femoral artery. The pulses in the legs were Vol. 115.May 1968
COMMENTS Dissection of the layers of the aorta seems to occur because the bevel of the needle lies partly within the lumen of the vessel and partly within the wall. Intramural injection then occurs from the applied pressure, especially with a diseased vessel. Usually only a small amount of dye is injected (about 1 cc.), and there are no sequelae. Occasionally, however, large amounts of contrast material are deposited intramurally; this 709
Coran and Tyler
710
A
B
FIG. 1. A, test injection of 7 cc. of 70 per cent Renografin. B, injection of 30 cc. of 70 per cent Renografin. In both films note the very dense concentration of dye, the very sharp cutoff of dye, and the absence of collateral vessels.
may cause occlusion of major aortic branches or produce a false extraluminal channel. A cardinal sign of an intramural injection is a sharply demarcated, persistent, dense collection of contrast medium. The column of contrast material equals or exceeds the diameter of the vessel injected. There may be no filling of the aortic branches if the injection is entirely intramural [11]. The sharp demarcation without the presence of collateral vessels is evidence of an intra-
FIG. 2. A transfemoral aortogram does not show any dissection. Note the stenosis in the right common iliac artery.
mural injection rather than of a complete aortic block, especially if femoral pulses are palpable. This sharp demarcation of abnormally dense dye is well demonstrated in Figure 1. Additional evidence of an intramural injection is often noted on the delayed roentgenograms. Here one sees the effects of occlusion of aortic branches (by either the intramural injection or the resultant dissecting aneurysm) if contrast medium enters the affected branch before occlusion occurs. The viscus supplied by the occluded branch is persistently opacified by contrast material trapped within it as a result of the loss of normal perfusion pressure. Although intramural injection of dye (usually less than 1 cc.) is seen in 10 per cent of lumbar aortograms, less than ten cases of aortic dissection secondary to translumbar aortography have been reported [8,9,11,12]. In many of these, no symptoms ever developed and recovery occurred without surgical intervention; some died of uremia from renal arterial occlusion, and some were successfully treated by arterial surgery. Only slight back pain developed in our patient during the occurrence of dissection and there was no pulse loss; however, the aortogram is diagnostic of dissection, which was proved at surgery. In this case, the radiographic appearance of the test injection of 7 cc. was characteristic of an intramural deposition of dye and should have alerted us to this occurrence with subsequent termination of the procedure at that point. Therefore, the test injection of a small volume of contrast material, in American
Journal of Surgery
Aortic
Dissection
addition to indicating whether a visceral vessel has been directly punctured, is helpful in demonstrating an intramural injection.
4. MCAFEE, J. G. A survey of complications
5. 6.
SUMMARY
A case of aortic dissection secondary to translumbar aortography is presented. The characteristic x-ray appearance of this event and the value of the test injection are emphasized. REFERENCES
1. CRAWFORD, E. S., BEALL, A. C., MOYER, J. H., and DEBAKEY, M. E. Complications of aortography. Surg. Gynec. 60 Obst., 104: 129, 1957. 2. BEALL, A. C., MORRIS, G. C., GARRETT, H. E., HENLEY, W. S., HALLMAN, G. L., CRAWFORD, E. S., COOLEY, D. A., and DEBAKEY, M. E. Translumbar aortography. Present indications and technics. Ann. Int. Med., 60: 843, 1964. 3. MCAFEE, J. G. and WILSON, J. K. I’. A review of the complications of translumbar aortography. Am. J. Roentgenol., 75: 956, 1956.
Vol. 115. May 1968
i.
8.
9.
10.
11.
12.
711
of abdominal aortography. Radiology, 68: 825, 1957. WAGNER, F. D. and PRICE, ,4. H. Fatality after abdominal arteriography. Surgery, 27: 621, 1950. AkNTONI, H. and LINDGRES, E. Steno’s experiment in man as complication in lumbar aortography. Acta chir. scandinazl., 98: 230, 1949. LARSON, II. and PALMLOV, A. Abdominal aortography with special reference to its complications. Acta radial., 38: 111, 1952. FINEBERG, C., SCHECHTER, D. C., and BARRICK, C. W. Gangrene of the large intestine and ovaries after translumbar aortography. J. A. 22f. A., 167: 1232, 1958. GAYLIS, H. and LAGS, J. W. Dissection of aorta as a complication of translumbar aortography. Brit. M. J., 2: 1141, 1956. GUDBJERG, C. E. and CHRISTENSEN,J. Dissection of the aortic wall in retrograde lumbar aortography. Acta radial., 55: 364, 1961. BOBLITT, D. E., FIGLEY, M. M., and WOLFMAN, E. F. Roentgen signs of contrast material dissection of aortic wall in direct aortography. Am. J. Roentgenol., 31: 826, 1959. SZILAGYI, D. E., SMITH, R. F., MACKSOOD, A. J., and EYLER, W. R. Abdominal aortography: its value and its hazards. .Ivch. Surg., 85: 25, 1962.