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Aortic dissection: timing and location of angiography caused delay in transfer
- Alan D Exton (27 June 2006)
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Alan D Exton, Senior House Officer Emergency Medicine, Scotland
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alan_exton{at}hotmail.com Alan D Exton
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Dear Editor, I read with interest the article by Domingo, Levy and Iosovich regarding an unusual presentation of traumatic aortic dissection. While appreciating that the case highlighted the need to consider the potential for injuries not solely due to direct, "penetrating" trauma but also those due to the "blunt" trauma of gunshot wounds, I would draw attention to the fact that it seems the patient underwent angiography prior to transfer to a hospital with a cardiothoracic service. Given the quoted mortality of aortic dissection, potential for rapid deterioration and the need for selective surgical management, I would have thought that whilst further imaging was indeed appropriate, the timing and location of the procedure was not. Having already made the diagnosis by demonstrating the dissection on CT, I would suggest that a better course of action would have been to liaise with the cardiothoracic unit and transfer the patient prior to angiography. While I would perhaps accept the sequence of events if it were clear that the patient would not have been transferred had the angiographic findings defined the dissection as suitable for purely medical management in the initial hospital, and that the CT findings were highly suggestive of this angiographic outcome, the criteria on which transfer of the patient were based are not stated in the article. Furthermore, given the diagnosis and the fact that the patient was indeed transferred, this outcome following angiography seems very unlikely. Subjecting the stable patient to an essentially non-diagnostic, quantitative angiography in the initial hospital surely exposed the patient to both unnecessary delay in transfer and an invasive procedure in a facility unable to deal adequately with the consequences of complications. These potentially significant risks surely mean that the alternative, transferring the patient prior to angiography, would have been preferable. |
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