Background-The management of aortic intramural hematoma (IMH) involving the ascending aorta (type A) has not been well-established. The purpose of this study was to clarify the long-term clinical outcomes of patients with type A IMH who were treated with medical therapy and timely operation. Methods and Results-Clinical data including operative mortality, IMH-related events, and long-term survival were retrospectively reviewed in 66 patients with type A IMH, who were admitted to our institution from 1986 to 2006. Emergent surgical repair was performed in 16 (24%) patients because of severe complications, whereas 50 patients were treated with initial medical therapy. In medically treated patients, 15 (30%) patients who demonstrated progression to classic dissection or increase in hematoma size within 30 days underwent surgical repair except for 2 patients who refused surgery. The 30-day mortality rate was 6% with emergent surgery and 4% with supportive medial therapy. There were 7 late deaths and the actuarial survival rates of all patients were 96Ϯ3%, 94Ϯ3%, and 89Ϯ5% at 1, 5, and 10 years, respectively. In medically treated patients, maximum aortic diameter was the only predictor of early and late progression of ascending IMH (hazard ratio, 4.43; 95% CI, 2.04 -9.64; PϽ0.001). Aortic diameter Ն50 mm predicted progression of ascending IMH with the positive and negative value of 83% and 84%, respectively. Conclusions-Combination

Internal mammary artery graft flow early after operation is characterized by a higher rest velocity than that of vein graft flow. This high velocity maintains flow volume at baseline condition in compensation for the smaller diameter. Although flow reserve does not differ significantly between new and old vein grafts, that for internal mammary artery grafts is significantly reduced soon after bypass surgery. This restricted flow capacity improves late postoperatively because of an increase in diameter and a decrease in flow velocity from baseline levels.

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