Acute Intramural Hematoma of the Aorta

Abstract

Background-The definition, prevalence, outcomes, and appropriate treatment strategies for acute intramural hematoma (IMH) continue to be debated. Methods and Results-We studied 1010 patients with acute aortic syndromes who were enrolled in the International Registry of Aortic Dissection (IRAD) to delineate the prevalence, presentation, management, and outcomes of acute IMH by comparing these patients with those with classic aortic dissection (AD). Fifty-eight (5.7%) patients had IMH, and this cohort tended to be older (68.7 versus 61.7 years; PϽ0.001) and more likely to have distal aortic involvement (60.3% versus 35.3%; PϽ0.001) compared with 952 patients with AD. Patients with IMH described more severe initial pain than did those with AD but were less likely to have ischemic leg pain, pulse deficits, or aortic valve insufficiency; moreover, they required a longer time to diagnosis and more diagnostic tests. Overall mortality of IMH was similar to that of classic AD (20.7% versus 23.9%; Pϭ0.57), as was mortality in patients with IMH of the descending aorta (8.3% versus 13.1%; Pϭ0.60) and the ascending aorta (39.1% versus 29.9%; Pϭ0.34) compared with AD. IMH limited to the aortic arch was seen in 7 patients, with no deaths, despite medical therapy in only 6 of the 7 individuals. Among the 51 patients whose initial diagnostic study showed IMH only, 8 (16%) progressed to AD on a serial imaging study. Conclusions-The IRAD data demonstrate a 5.7% prevalence of IMH in patients with acute aortic syndromes. Like classic AD, IMH is a highly lethal condition when it involves the ascending aorta and surgical therapy should be considered, but this condition is less critical when limited to the arch or descending aorta. Fully 16% of patients have evidence of evolution to dissection on serial imaging.

Editor's Choice – Management of Descending Thoracic Aorta Diseases

“…6 IMH may be related to PAU, accounting for 5e20% of patients with AAS and more commonly involving the DTA (60%) than the ascending aorta. 7 Trauma is the leading cause of death during the first four decades of life, accounting for more than 250,000 deaths every year in the European Union alone. 8 Blunt aortic injury is the second leading cause of death in these patients, and although it occurs in less than 1% of all motor vehicle accidents, it accounts for 16% of all traumatic deaths.…”

“…119 The natural history of type B IMH is similar to that of ATBAD. 7,51 Conservative medical treatment is used for isolated uncomplicated type B IMH. 120 Treatment with bblockers has a survival rate of 95%, compared with 67% for those treated without b-blockade.…”

Differential aspects of ascending thoracic aortic dissection and its treatment: the North American experience

“…The majority of intramural hematomas occur in the descending aorta. Patients with intramural hematoma are usually older and more hypertensive than patients with classic acute aortic dissection (1,2). The hematoma can be focal or can extend proximally and distally.…”

Akutes Aortensyndrom

“…Die A. descendens ist in etwa 60 % der Fälle betroffen, bei Lokalisation des IMH im Bereich der A. ascendens ist wie bei der Typ-A-AD die Mortalität erhöht [14]. [23].…”