Intramural haematoma of the thoracic aorta: who's to be alerted the cardiologist or the cardiac surgeon?

Abstract

This review article is written so as to present the pathophysiology, the symptomatology and the ways of diagnosis and treatment of a rather rare aortic disease called Intra-Mural Haematoma (IMH). Intramural haematoma is a quite uncommon but potentially lethal aortic disease that can strike as a primary occurrence in hypertensive and atherosclerotic patients to whom there is spontaneous bleeding from vasa vasorum into the aortic wall (media) or less frequently, as the evolution of a penetrating atherosclerotic ulcer (PAU). IMH displays a typical of dissection progress, and could be considered as a precursor of classic aortic dissection. IMH enfeebles the aortic wall and may progress to either outward rupture of the aorta or inward disruption of the intima layer, which ultimately results in aortic dissection. Chest and back acute penetrating pain is the most commonly noticed symptom at patients with IMH. Apart from a transesophageal echocardiography (TEE), a tomographic imaging such as a chest computed tomography (CT), a magnetic resonance (MRI) and most lately a multy detector computed tomography (MDCT) can ensure a quick and accurate diagnosis of IMH. Similar to type A and B aortic dissection, surgery is indicated at patients with type-A IMH, as well as at patients with a persistent and/or recurrent pain. For any other patient (with type-B IMH without an incessant pain and/or without complications), medical treatment is suggested, as applied in the case of aortic dissection. The outcome of IMH in ascending aorta (type A) appears favourable after immediate (emergent or urgent) surgical intervention, but according to international bibliography patients with IMH of the descending aorta (type B) show similar mortality rates to those being subjected to conservative medical or surgical treatment. Endovascular surgery and stent-graft placement is currently indicated in type B IMH.

Aortic Intramural Hematoma and Its Complications

“…3,5,6 Other mechanisms include pathological neovascularization, with an increase in microvessels and spontaneous bleeding in the arterial plaque. This mechanism is similar to both the rupture of coronary atherosclerotic plaque, which results in myocardial infarction, and to intimal fracture of an atheromatous plaque, which results in intramedial propagation of blood and IMH formation.…”

“…This mechanism is similar to both the rupture of coronary atherosclerotic plaque, which results in myocardial infarction, and to intimal fracture of an atheromatous plaque, which results in intramedial propagation of blood and IMH formation. [3][4][5][6] IMH can also be caused by microscopic tears in the aortic intima or from a PAU. 3,[5][6][7] PAU contributes to a small proportion of IMHs, and although rare, thoracic trauma may cause IMH.…”

“…[3][4][5][6] IMH can also be caused by microscopic tears in the aortic intima or from a PAU. 3,[5][6][7] PAU contributes to a small proportion of IMHs, and although rare, thoracic trauma may cause IMH. PAU, an uncommon cause of type A IMH, is a condition in which ulceration of an aortic atheromatous plaque is initially confined to the intimal layer.…”

Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches

“…77 Less commonly, an IMH may develop as a result of a PAU or thoracic trauma. 78 According to Nienaber et al, 79 Krukenberg first described an IMH in 1920 as a "dissection without intimal tear." This variation of aortic dissection was considered a distinct entity at postmortem examination.…”

Penetrating Atherosclerotic Ulcer of Aorta: A Giant Lurking in the Dark

“…17 Given the substantial morbidity associated with conventional surgery, endovascular repair is an attractive and challenging alternative method in these highrisk patients. 18,19,20 ConClUsIon PAU affects elderly, who usually have comorbidities. Patients with PAU involving the descending aorta can initially be treated conservatively by aggressive medical therapy.…”