Prognosis of Aortic Intramural Hematoma With and Without Penetrating Atherosclerotic Ulcer

Abstract

Background-Advances in imaging techniques have increased the recognition of aortic intramural hematomas (IMHs) and penetrating atherosclerotic ulcers (PAUs); however, distinction between IMH and PAU remains unclear. We intended to clarify differences between IMH coexisting with PAU and IMH not associated with PAU by comparisons of clinical features, imaging findings, and patient outcome to derive the optimal therapeutic approach. Methods and Results-We performed a retrospective analysis of 65 symptomatic patients with aortic IMH. There were 34 patients with IMH associated with PAU (group 1) and 31 patients with IMH unaccompanied by PAU (group 2). Involvement of the ascending aorta (type A) was more frequent in group 2 (8 of 31, 26%), whereas most of the patients in group 1 had exclusive involvement of the descending aorta (type B) (31of 34, 91%). Patients were subdivided into 2 categories, those with clinical progression and those with stable disease. Forty-eight percent of patients in group 1 and 8% in group 2 were in the progressive category (Pϭ0.002). Clinical and radiological findings were compared between those group 1 patients who had a progressive disease course (nϭ12) and those who were stable (nϭ13). Sustained or recurrent pain (PϽ0.0001), increasing pleural effusion (Pϭ0.0003), and both the maximum diameter (Pϭ0.004) and maximum depth (Pϭ0.003) of the PAU were reliable predictors of disease progression. Considered by many to be a variant of aortic dissection, the pathogenesis of IMH still remains unclear. Two different pathophysiological processes can lead to intramural hematoma formation. One is IMH without intimal disruption; in this entity, it is believed that spontaneous rupture of aortic vasa vasorum is responsible for hematoma formation within the aortic wall. 1 The other type of IMH is associated with an atherosclerotic ulcer that penetrates into the internal elastic lamina and allows hematoma formation within the media of the aortic wall. [2][3][4] Conclusions-This See p 284In previous reports, these 2 types of IMH are rarely distinguished in discussing prognoses and optimal treatment methods. 3,5,6 The concept of the Stanford classification scheme for aortic dissection has been applied to IMH because the prognostic impact of the location of IMH and its standard treatment have been considered similar to those for classic aortic dissection. 5 It is generally accepted that patients with type B (exclusive involvement of the descending aorta) IMH can be managed conservatively in the absence of disease progression, whereas early surgical interventions are recommended for type A (involvement of the ascending aorta) IMH. 5,6 On the other hand, Coady et al 7 recently reported that the prognoses of acutely symptomatic hospitalized patients with penetrating atherosclerotic ulcers (PAUs) was worse than those with classic aortic dissection due to a higher incidence of aortic rupture.We reviewed 65 symptomatic patients with aortic IMH. Thirty-four patients had a PAU that was considered to be the cause of I...

Aortic Dissection: New Frontiers in Diagnosis and Management

“…[61][62][63][64][65] Noninvasive imaging of aortic ulceration has been improved by tomographic scanning and has shed light on pathophysiology and etiology. The ulcers seem to predominantly affect the descending thoracic aorta, as well as the abdominal aorta, in localized fashion; branch vessel compromise is rare.…”

“…The ulcers seem to predominantly affect the descending thoracic aorta, as well as the abdominal aorta, in localized fashion; branch vessel compromise is rare. However, ulcers may penetrate intimal borders, often appearing in nipple-like projection with an adjacent hematoma 62,65 ; symptomatic ulcers and/or those with signs of deep erosion are more likely to rupture than others.…”

“…38 Plaque ulceration after plaque rupture is typically visualized by TEE, CT, or MRI. 46,[62][63][64][65] In case of multiple lesions, each one has to be carefully checked for signs of penetration or rupture, as evidenced by fluid extravasation into the pericardium, pleural space, and/or mediastinum, which often heralds the risk of sudden death from exsanguination. 56,74 The presence of pericardial fluid around the aortic root is a sign of ongoing penetration or imminent perforation regardless of dissection or IMH.…”

Acute Aortic Syndrome: Recent Trends in Imaging Assessment Using Computed Tomography Angiography

“…Indications for endovascular treatment of IMH are basically the same as those for dissection: medical treatment with serial imaging follow-up for type B aortic IMH and immediate surgical treatment for type A aortic IMH [21,38]. During the followup period of type B aortic IMH, if a gradual increase in IMH thickness, luminal dilatation, pseudoaneurysm formation (or ulcer-like projection), or progression to aortic dissection occurs, surgical or endovascular treatment is required [38].…”

Ruptura dos vasa vasorum e hematoma intramural da aorta: um paradigma em mudança

“…[23][24][25] The relation between VV rupture and intramural hematoma was first established in 1920 by Krukenberg et al; 26 since then, IMH has been accepted as a possible cause. IMH is by definition distinguished from acute dissection and hematoma secondary to penetrating ulcer due to the absence of an intimal rupture site.…”