Table of contents
Aortic intramural hematoma
What's new
Updated 2024 ESC guidelines for the evaluation and management of aortic intramural hematoma.
Background
Overview
Definition
Aortic IMH is a condition characterized by bleeding within the wall of the aorta without an entrance tear.
1
Pathophysiology
The pathophysiology of aortic IMH involves two main mechanisms: extension of aortic dissection and primary intimal tear with hematoma propagation.
2
Epidemiology
The incidence of aortic IMH is estimated at 1.2 per 100,000 person-years.
3
Disease course
Clinically, patients with aortic IMH often present with sudden, severe, and persistent chest or back pain. Complications include progression to aortic dissection or rupture.
1
4
Prognosis and risk of recurrence
The prognosis of aortic IMH can vary based on factors such as the extent and location of the hematoma. It usually carries a lower mortality rate than aortic dissection.
5
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of aortic intramural hematoma are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2024), the Society of Thoracic Surgeons (STS/EACTS 2024), the American Heart Association (AHA/ACC 2022), the American Association for Thoracic Surgery (AATS 2021), and the Society for Cardiovascular Angiography and Interventions (SCAI/STS/SVM/AATS/SCA/AHA/ACR/ACC/ASA/SIR ...
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Classification and risk stratification
Diagnostic investigations
Aortic imaging
As per ESC 2024 guidelines:
Obtain ECG-gated cardiovascular CT from neck to pelvis as first-line imaging technique in patients with suspected acute aortic syndrome.
B
Consider obtaining cardiovascular MRI as an alternative if cardiovascular CT is not available in patients with suspected acute aortic syndrome.
C
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Echocardiography
Medical management
Nonpharmacologic interventions
Surgical interventions
Indications for surgery
As per ESC 2024 guidelines:
Perform urgent surgery in patients with type A IMH.
B
Consider performing surgery in patients with complicated type B IMH with unfavorable anatomy for TEVAR.
C
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TEVAR
Specific circumstances
Patients with penetrating atherosclerotic ulcer, initial medical therapy: as per ESC 2024 guidelines, provide medical therapy including pain relief and BP control in all patients with penetrating atherosclerotic ulcers.
B
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Patients with penetrating atherosclerotic ulcer (indications for repair)
Patients with penetrating atherosclerotic ulcer (TEVAR)
Patients with penetrating atherosclerotic ulcer (open repair)
Patients with penetrating atherosclerotic ulcer (surveillance)