Intramural Hematoma and Penetrating Ulcer
Sundt PAU and IMH Summary
Intramural hematoma and penetrating ulcer represent the so-called variant forms of aortic dissection which complete the triad accountable for the vast majority of acute aortic syndromes. Although they may also occur in chronic forms, their management is most often discussed in the context of the acute presentation. Penetrating ulcers are uncommon and most frequently occur in the elderly with advanced occlusive atherosclerotic disease. They most often present in the descending thoracic aorta and are accompanied by at least a local intramural hemorrhage. There continues to be controversy over their natural history. The most recent series from the Mayo Clinic suggests that the majority may be managed in the acute setting nonoperatively with aggressive blood pressure control. Nonetheless, they run the risk of late evolution to saccular pseudoaneurysm or dissection. Likewise, intramural hematomas most often occur in the descending thoracic aorta and can most often be treated nonoperatively. They too run the risk of progression to more extensive disease. When either of these entities involve the ascending aorta, surgical intervention is the conventional approach. The role of endovascular stent grafting for either of these conditions remains in evolution and is dependent on a more complete understanding of their natural history.
KeywordsAortic Dissection Thoracic Aorta Intramural Hematoma Thoracic Aortic Aneurysm Acute Aortic Syndrome
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