Intimal Tear Without Hematoma

“…If a high clinical suspicion exists for acute aortic dissection but initial aortic imaging is negative, a second imaging study should be obtained. 85 (Level of Evidence: C)…”

Section: E60mentioning

confidence: 99%

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary

Hiratzka

Bakris

Beckman

et al. 2010

Cathet Cardio Intervent

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279

105

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“…4) For the differentiation between the two types of aortic dissection, the former is referred to as classic or communicating aortic dissection, and the latter as IMH or non-communicating aortic dissection. In IMH, no entry tear or false lumen flow is observed, strongly suggesting that no intimal tear exists anatomically.…”

Section: Medial Weakness: a Pathological Problem With Aortic Dissectionmentioning

confidence: 99%

Pathogenesis of Aortic Dissection: Elastic Fiber Abnormalities and Aortic Medial Weakness

Nakashima

2010

Annals of Vascular Diseases

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A lthough aortic dissection was previously a disease with an extremely poor prognosis, recent advances in diagnostic imaging and therapeutic modalities may improve its prognosis.1, 2) However, much of its etiology and pathogenesis remains unknown. In addition, new pathological variants of aortic dissection, such as intramural hematoma (IMH) and penetrating atherosclerotic ulcer, and related diseases have been identified, raising a new problem. Against this background, this paper revisits the basic pathology of aortic dissection, and discusses the structural abnormalities of the aortic media and mechanism of aortic dissection, as extrapolated from them. Medial Weakness: A Pathological Problem with Aortic DissectionAortic dissection used to be clearly defined as a pathological condition characterized by the presence of an aortic intimal tear and medial dissection, that is, a condition in which blood flows from the entry site into the false lumen.3) However, advances in diagnostic imaging have resulted in the identification of aortic dissection with no entry tear or false lumen flow, and these variants were included in the category of aortic dissection.4) For the differentiation between the two types of aortic dissection, the former is referred to as classic or communicating aortic dissection, and the latter as IMH or non-communicating aortic dissection. In IMH, no entry tear or false lumen flow is observed, strongly suggesting that no intimal tear exists anatomically. However, the limitations of diagnostic imaging make it difficult to establish its presence or absence. Therefore, it is doubtful whether IMH should be treated as the same entity as classic aortic dissection. However, in some cases, IMH has a poor prognosis in that it progresses to classic aortic dissection, or ruptures. Thus, clinically, it is believed that it is not contradictory to treat IMH as a variant of aortic dissection. 5,6) In contrast, pathologically, since the diagnosis can be confirmed by autopsy, IMH is clearly defined as a dissection without an intimal tear. 7,8) However, at the same time, the important question of whether dissection with a tear (classic aortic dissection) and that without a tear (IMH) is the same disease arises. This is related to the long-standing debate over which occurs first, intimal tear or medial dissection, in the development of aortic dissection. The former is the hypothesis that a crack (intimal tear) first forms in the intima overlying a site of aortic medial weakness, followed by blood inflow from the lumen, resulting in medial dissection.9) This is a very natural way of thinking in terms of the direction of blood flow. However, from this viewpoint, it follows that no dissection occurs without an intimal tear, making it contradictory to include IMH in the category of aortic dissection. On the other hand, the latter is based on the fact that no intimal tears were identified in about 10% of autopsied patients with aortic dissection, leading to a hypothesis that bleeding from the medial vasa vasorum at a site o...

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“…19 Thus, our finding that effective oral ␤-blocker therapy infers a reduced rate of late progression is novel but not unexpected in IMH, considering the beneficial impact of vigorously lowering the driving force for dissection. 21 The observation that older age (Ͼ56 years) at initial diagnosis of IMH is related to better long-term prognosis may be explained by more focal microscars along the aortic wall inherently limiting a longitudinal extension of IMH. 1,12 Accordingly, favorable outcomes of IMH are consistently reported in patients beyond 65 years.…”

Section: Prediction Of Late Progressionmentioning

confidence: 99%

Intramural hematoma of the aorta: predictors of progression to dissection and rupture

Kodolitsch¹,

Csösz²,

Koschyk³

2003

ACC Current Journal Review

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Background-Aortic intramural hematoma (IMH) is a variant of overt aortic dissection. The predictors of progression of IMH to dissection and rupture are still unknown, and strategies for management are not established. Methods and Results-A multicenter study was conducted comprising 66 patients with IMH and hospital admission Յ48 hours after onset of initial symptoms. Among these, progression to aortic dissection or rupture occurred in 30 (45%) and death occurred in 13 (20%) patients within 30 days. Late progression was noted in 14 (21%) and death in 11 (17%) patients, yielding a 1-, 2-, and 5-year survival of 76%, 73%, and 43%, respectively. In a set of 9 variables, multivariate analysis identified IMH location in the ascending aorta (type A; Pϭ0.02) and moderately ectatic aortic diameters (49Ϯ13 mm with progression versus 57Ϯ16 mm without progression; Pϭ0.03) as independent predictors of early progression. In type A IMH, early mortality was 8% with swift surgery versus 55% without surgery (Pϭ0.004). The risk of late progression of IMH was independently associated with age at index diagnosis (Pϭ0.01) and absence of ␤-blocker therapy during follow-up (Pϭ0.03). Kaplan-Meier analysis confirmed improved 1-year survival of IMH with ␤-blocker therapy (95% versus 67% without ␤-blockers; Pϭ0.004). Conclusions-Regardless of aortic diameter, IMH of the ascending aorta (type A) is at high risk for early progression, and, thus, undelayed surgical repair should be performed. Moreover, oral ␤-blocker therapy may improve long-term prognosis of IMH independent of anatomical location.

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Intimal Tear Without Hematoma

Cited by 288 publications

References 26 publications

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary

Pathogenesis of Aortic Dissection: Elastic Fiber Abnormalities and Aortic Medial Weakness

Intramural hematoma of the aorta: predictors of progression to dissection and rupture

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