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Aortic intramural hematoma

What's new

Updated 2024 EACTS/STS guidelines for the 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.
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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 Society of Thoracic Surgeons (STS/EACTS 2024), the American Heart Association (AHA/ACC 2022), the American Association for Thoracic Surgery (AATS 2021), the European Society of Cardiology (ESC 2014), 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

Classification: as per EACTS/STS 2024 guidelines, consider using the TEM classification in any acute aortic syndrome to identify the disease type and establish an initial treatment strategy.
C
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Diagnostic investigations

Diagnostic imaging: as per ESC 2014 guidelines, consider obtaining MRI for characterizing acute IMHs when CT is equivocal.
C

Medical management

Expectant management: as per EACTS/STS 2024 guidelines, consider offering optimal medical therapy with serial imaging in patients with type A aortic IMH in the absence of high-risk features.
C
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Nonpharmacologic interventions

Physical activity: as per EACTS/STS 2024 guidelines, educate patients about the specific risks and benefits of exercise.
B
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Surgical interventions

Indications for surgery
As per EACTS/STS 2024 guidelines:
Perform emergency surgery in patients with acute type A aortic IMH with complications or high-risk features.
B
Perform urgent aortic repair in patients with acute complicated type B aortic IMH.
B

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Specific circumstances

Patients with penetrating atherosclerotic ulcer: as per EACTS/STS 2024 guidelines, perform urgent aortic repair in patients with penetrating aortic ulcer located in the ascending aorta in the presence of IMH or rupture.
B
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Follow-up and surveillance

Surveillance imaging: as per EACTS/STS 2024 guidelines, establish an individual surveillance program for patients receiving aortic pathology treatment based on disease and treatment, conducted at a specialized aortic center with a dedicated outpatient clinic.
B
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