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Aortic intramural hematoma
Aortic intramural hematoma is a condition characterized by bleeding within the wall of the aorta without an entrance tear.
The pathophysiology of aortic intramural hematoma involves two main mechanisms: extension of aortic dissection and primary intimal tear with hematoma propagation.
The incidence of aortic intramural hematoma is estimated at 1.2 per 100,000 person-years.
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.
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.
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).
Diagnostic imaging: consider obtaining MRI for characterizing acute intramural hematomas when CT is equivocal.
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.
Offer medical therapy as the initial management strategy in patients with uncomplicated acute type B intramural hematoma.
Open surgery: as per AHA 2022 guidelines, perform urgent repair in patients with complicated acute type A or B aortic intramural hematoma.
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Patients with penetrating atherosclerotic ulcer
Perform urgent repair in patients with penetrating atherosclerotic ulcer of the ascending aorta with associated intramural hematoma.
Consider performing urgent repair in patients with penetrating atherosclerotic ulcer of the aortic arch, descending thoracic aorta, or abdominal aorta with associated intramural hematoma.
5.Follow-up and surveillance
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.
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.