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Intramural Hematoma and Penetrating Ulcer

VIII International Symposium on Advances in Understanding Aortic Diseases Tokyo, 2007
  • Thoralf M. SundtIII
Conference paper

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.

Keywords

Aortic Dissection Thoracic Aorta Intramural Hematoma Thoracic Aortic Aneurysm Acute Aortic Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Svensson LG, Labib SB, Eisenhauer AC, et al (1999) Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation 99:1331–6PubMedGoogle Scholar
  2. 2.
    Sundt TM (2007) Intramural hematoma and penetrating atherosclerotic ulcer of the aorta. Ann Thorac Surg 83:S835–41; discussion S846–50PubMedCrossRefGoogle Scholar
  3. 3.
    Agmon Y, Khandheria BK, Meissner I, et al (2003) Is aortic dilatation an atherosclerosis-related process? Clinical, laboratory, and transesophageal echocardiographic correlates of thoracic aortic dimensions in the population with implications for thoracic aortic aneurysm formation. J Am Coll Cardiol 42:1076–83PubMedCrossRefGoogle Scholar
  4. 4.
    Achneck H, Modi B, Shaw C, et al (2005) Ascending thoracic aneurysms are associated with decreased systemic atherosclerosis. Chest 128:1580–6PubMedCrossRefGoogle Scholar
  5. 5.
    Krukenberg E (1920) Beitrage zur Frage des Aneurysma dissecans. Beitr Pathol Anat Allg Pathol 67:329–51Google Scholar
  6. 6.
    Stanson AW, Kazmier FJ, Hollier LH, et al (1986) Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Annals of Vascular Surgery 1:15–23PubMedGoogle Scholar
  7. 7.
    Cho KR, Stanson AW, Potter DD, et al (2004) Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch. J Thorac Cardiovasc Surg 127:1393–9; discussion 1399–1401PubMedCrossRefGoogle Scholar
  8. 8.
    Ganaha F, Miller DC, Sugimoto K, et al (2002) Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation 106:342–8PubMedCrossRefGoogle Scholar
  9. 9.
    Vilacosta I, Roman JA (2001) Acute aortic syndrome. Heart 85:365–8PubMedCrossRefGoogle Scholar
  10. 10.
    Hussain S, Glover JL, Bree R, Bendick PJ (1989) Penetrating atherosclerotic ulcers of the thoracic aorta. Journal of Vascular Surgery 9:710–7PubMedCrossRefGoogle Scholar
  11. 11.
    Kazerooni EA, Bree RL, Williams DM (1992) Penetrating atherosclerotic ulcers of the descending thoracic aorta: evaluation with CT and distinction from aortic dissection. Radiology 183:759–65PubMedGoogle Scholar
  12. 12.
    Tittle SL, Lynch RJ, Cole PE, et al (2002) Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta. Journal of Thoracic & Cardiovascular Surgery 123:1051–9CrossRefGoogle Scholar
  13. 13.
    Absi TS, Sundt TM 3rd, Camillo C, et al (2004) Penetrating atherosclerotic ulcers of the descending thoracic aorta may be managed expectantly. Vascular 12:307–11PubMedCrossRefGoogle Scholar
  14. 14.
    Demers P, Miller DC, Mitchell RS, et al (2004) Stent-graft repair of penetrating atherosclerotic ulcers in the descending thoracic aorta: mid-term results. Ann Thorac Surg 77:81–6PubMedCrossRefGoogle Scholar
  15. 15.
    Eggebrecht H, Herold U, Schmermund A, et al (2006) Endovascular stent-graft treatment of penetrating aortic ulcer: results over a median follow-up of 27 months. Am Heart J 151:530–6PubMedCrossRefGoogle Scholar
  16. 16.
    Piffaretti G, Tozzi M, Lomazzi C, et al (2007) Penetrating ulcers of the thoracic aorta: results from a single-centre experience. Am J Surg 193:443–7PubMedCrossRefGoogle Scholar
  17. 17.
    Evangelista A, Mukherjee D, Mehta RH, et al (2005) Acute Intramural Hematoma of the Aorta. A Mystery in Evolution. Circulation 111:1063–70PubMedCrossRefGoogle Scholar
  18. 18.
    Gore I (1952) Pathogenesis of dissecting aneurysm of the aorta. AMA Arch Pathol 53:142–53PubMedGoogle Scholar
  19. 19.
    Hirst AE Jr., Johns VJ Jr., Kime SW (1958) Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore) 37:217–279Google Scholar
  20. 20.
    Maraj R, Rerkpattanapipat P, Jacobs LE, et al (2000) Meta-analysis of 143 reported cases of aortic intramural hematoma. American Journal of Cardiology. 86:664–8PubMedCrossRefGoogle Scholar
  21. 21.
    Sawhney NS, DeMaria AN, Blanchard DG (2001) Aortic intramural hematoma: an increasingly recognized and potentially fatal entity. Chest 120:1340–6PubMedCrossRefGoogle Scholar
  22. 22.
    Vaccari G, Caciolli S, Calamai G, et al (2001) Intramural hematoma of the aorta: diagnosis and treatment. Eur J Cardiothorac Surg 19:170–3PubMedCrossRefGoogle Scholar
  23. 23.
    Yamada T, Tada S, Harada J (1988) Aortic dissection without intimal rupture: diagnosis with MR imaging and CT. Radiology 168:347–52PubMedGoogle Scholar
  24. 24.
    Song JK, Kim HS, Kang DH, et al (2001) Different clinical features of aortic intramural hematoma versus dissection involving the ascending aorta. J Am Coll Cardiol 37:1604–10PubMedCrossRefGoogle Scholar
  25. 25.
    Shimizu H, Yoshino H, Udagawa H, et al (2000) Prognosis of aortic intramural hemorrhage compared with classic aortic dissection. American Journal of Cardiology 85:792–5PubMedCrossRefGoogle Scholar
  26. 26.
    Kaji S, Nishigami K, Akasaka T, et al (1999) Prediction of progression or regression of type A aortic intramural hematoma by computed tomography. Circulation 100:II281–6PubMedGoogle Scholar
  27. 27.
    Kaji S, Akasaka T, Horibata Y, et al (2002) Long-term prognosis of patients with type a aortic intramural hematoma. Circulation 106:I248–52PubMedGoogle Scholar
  28. 28.
    von Kodolitsch Y, Csosz SK, Koschyk DH, et al (2003) Intramural hematoma of the aorta: predictors of progression to dissection and rupture. Circulation 107:1158–63CrossRefGoogle Scholar
  29. 29.
    Estrera AL, Miller CC, Goodrick J, et al (2007) Update on outcomes of acute type B aortic dissection. Ann Thorac Surg 83:S842–5; discussion S846–50PubMedCrossRefGoogle Scholar
  30. 30.
    Juvonen T, Ergin MA, Galla JD, et al (1999) Risk factors for rupture of chronic type B dissections. J Thorac Cardiovasc Surg 117:776–86PubMedCrossRefGoogle Scholar
  31. 31.
    Uchida K, Imoto K, Takahashi M, et al (2005) Pathologic characteristics and surgical indications of superacute type A intramural hematoma. Ann Thorac Surg 79:1518–21PubMedCrossRefGoogle Scholar
  32. 32.
    Coady MA, Rizzo JA, Hammond GL, et al (1999) Surgical intervention criteria for thoracic aortic aneurysms: a study of growth rates and complications. Ann Thorac Surg 67:1922–6; discussion 1953–8PubMedCrossRefGoogle Scholar
  33. 33.
    Kaji S, Akasaka T, Katayama M, et al (2003) Long-term prognosis of patients with type B aortic intramural hematoma. Circulation 108:9CrossRefGoogle Scholar
  34. 34.
    Nienaber CA, von Kodolitsch Y, Petersen B, et al (1995) Intramural hemorrhage of the thoracic aorta. Diagnostic and therapeutic implications. Circulation 92:1465–72PubMedGoogle Scholar
  35. 35.
    Robbins RC, McManus RP, Mitchell RS, et al (1993) Management of patients with intramural hematoma of the thoracic aorta. Circulation 88:II1–II10.PubMedGoogle Scholar
  36. 36.
    Song JK, Kim HS, Song JM, et al (2002) Outcomes of medically treated patients with aortic intramural hematoma. Am J Med 113:181–7PubMedCrossRefGoogle Scholar
  37. 37.
    Nishigami K, Tsuchiya T, Shono H, et al (2000) Disappearance of aortic intramural hematoma and its significance to the prognosis. Circulation 102:III243–7PubMedGoogle Scholar
  38. 38.
    Sueyoshi E, Imada T, Sakamoto I, et al (2002) Analysis of predictive factors for progression of type B aortic intramural hematoma with computed tomography. Journal of Vascular Surgery 35:1179–83PubMedCrossRefGoogle Scholar
  39. 39.
    Sueyoshi E, Sakamoto I, Uetani M, Matsuoka Y (2006) CT analysis of the growth rate of aortic diameter affected by acute type B intramural hematoma. AJR Am J Roentgenol 186:S414–20PubMedCrossRefGoogle Scholar
  40. 40.
    Sueyoshi E, Matsuoka Y, Sakamoto I, et al (1997) Fate of intramural hematoma of the aorta: CT evaluation. J Comput Assist Tomogr 21:931–8PubMedCrossRefGoogle Scholar
  41. 41.
    Moriyama Y, Yotsumoto G, Kuriwaki K, et al (1998) Intramural hematoma of the thoracic aorta. Eur J Cardiothorac Surg 13:230–9PubMedCrossRefGoogle Scholar
  42. 42.
    Moizumi Y, Komatsu T, Motoyoshi N, et al (2002) Management of patients with intramural hematoma involving the ascending aorta. J Thorac Cardiovasc Surg 124:918–24PubMedCrossRefGoogle Scholar
  43. 43.
    Song JM, Kim HS, Song JK, et al (2003) Usefulness of the initial noninvasive imaging study to predict the adverse outcomes in the medical treatment of acute type A aortic intramural hematoma. Circulation 108:II324–8PubMedCrossRefGoogle Scholar
  44. 44.
    Song JK, Kang SJ, Song JM, et al (2007) Factors associated with in-hospital mortality in patients with acute aortic syndrome involving the ascending aorta. Int J Cardiol 115:14–8PubMedCrossRefGoogle Scholar
  45. 45.
    Mohr-Kahaly S (2001) Aortic intramural hematoma: from observation to therapeutic strategies. J Am Coll Cardiol 37:1611–3PubMedCrossRefGoogle Scholar
  46. 46.
    Long SM, Tribble CG, Raymond DP, et al (2003) Preoperative shock determines outcome for acute type A aortic dissection. Ann Thorac Surg 75:520–4PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2009

Authors and Affiliations

  • Thoralf M. SundtIII
    • 1
  1. 1.Professor of Surgery and ConsultantVice-Chair Department of Surgery Mayo ClinicRochester

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