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Aortic intramural hematoma

Definition
Aortic intramural hematoma is a condition characterized by bleeding within the wall of the aorta without an entrance tear.
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Pathophysiology
The pathophysiology of aortic intramural hematoma involves two main mechanisms: extension of aortic dissection and primary intimal tear with hematoma propagation.
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Epidemiology
The incidence of aortic intramural hematoma is estimated at 1.2 per 100,000 person-years.
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Disease course
Clinically, patients with aortic intramural hematoma often present with sudden, severe, and persistent chest or back pain. Complications include progression to aortic dissection or rupture.
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Prognosis and risk of recurrence
The prognosis of aortic intramural hematoma 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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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 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 2010).
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Guidelines

1.Diagnostic investigations

Diagnostic imaging: consider obtaining MRI for characterizing acute intramural hematomas when CT is equivocal.
C
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2.Medical management

Expectant management
As per AHA 2022 guidelines:
Consider offering an initial or expectant approach of medical management in selected patients with uncomplicated acute type A intramural hematoma at increased operative risk without high-risk imaging features.
C
Offer medical therapy as the initial management strategy in patients with uncomplicated acute type B intramural hematoma.
B

3.Surgical interventions

Open surgery: as per AHA 2022 guidelines, perform urgent repair in patients with complicated acute type A or B aortic intramural hematoma.
B
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4.Specific circumstances

Patients with penetrating atherosclerotic ulcer
Perform urgent repair in patients with penetrating atherosclerotic ulcer of the ascending aorta with associated intramural hematoma.
B
Consider performing urgent repair in patients with penetrating atherosclerotic ulcer of the aortic arch, descending thoracic aorta,
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or abdominal aorta with associated intramural hematoma.
C

5.Follow-up and surveillance

Surveillance imaging
As per AHA 2022 guidelines:
Obtain surveillance CT or MRI after 1 month, 6 months, and 12 months and then, if stable, annually thereafter in patients experienced acute aortic dissection and intramural hematoma managed with medical therapy alone.
B
Obtain surveillance CT or MRI after 1 month, 6 months, and 12 months and then, if stable, annually thereafter in patients experienced acute aortic dissection and intramural hematoma treated with either open or endovascular aortic repair and having a residual aortic disease.
B