Intramural Hematoma and Penetrating Atherosclerotic Ulcer of the Aorta

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Presentation transcript:

Intramural Hematoma and Penetrating Atherosclerotic Ulcer of the Aorta Thoralf M. Sundt, MD The Annals of Thoracic Surgery Volume 83, Issue 2, Pages S835-S841 (February 2007) DOI: 10.1016/j.athoracsur.2006.11.019 Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) The traditional concept of acute aortic syndromes places the three entities acute dissection, intramural hematoma (IMH), and penetrating ulcer (PAU), along a one-dimensional “spectrum” of disease. (B) An alternative view characterizes these entities on a two-dimensional spectrum descriptive of medial and intimal disease. The Annals of Thoracic Surgery 2007 83, S835-S841DOI: (10.1016/j.athoracsur.2006.11.019) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 The gross appearance of the intimal surface is strikingly different between the typical patient with (A) penetrating aortic ulcer and (B) acute dissection. In the case of the former, marked thickening of the intima with multiple ulcerlike craters is appreciated, whereas in the latter, the typical thin, pliable septum with a smooth intima is apparent. The Annals of Thoracic Surgery 2007 83, S835-S841DOI: (10.1016/j.athoracsur.2006.11.019) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Intraoperative inspection of segmental intramural hematoma may provide convincing proof of (A) an intact intima, consonant with (B) the impression from computed tomography scanning. The Annals of Thoracic Surgery 2007 83, S835-S841DOI: (10.1016/j.athoracsur.2006.11.019) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) A crescentic intramural hematoma involving the ascending aorta (Ao) may demonstrate areas of lucency (arrows) by transepsophageal echocardiography. (B) Intramural hematoma can also appear as a concentric thrombus involving the ascending aorta, as shown on this computed tomography scan. The Annals of Thoracic Surgery 2007 83, S835-S841DOI: (10.1016/j.athoracsur.2006.11.019) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Meta-analysis by Maraj and colleagues [12] of the outcome of 143 cases of intramural hematoma reported in the literature confirms the appropriateness of operative therapy for those involving the ascending aorta, and nonoperative management of those sparing the ascending aorta. The risk ratios (RR) and 95% confidence intervals (CI) are provided. The Annals of Thoracic Surgery 2007 83, S835-S841DOI: (10.1016/j.athoracsur.2006.11.019) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Both early and late survival of intramural hematoma is superior to that for acute dissection in this study by Kaji and associates [24]. The Annals of Thoracic Surgery 2007 83, S835-S841DOI: (10.1016/j.athoracsur.2006.11.019) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Representative axial images obtained by computed tomography without intravenous contrast demonstrate heavy, concentric calcification of the ascending aorta surrounding the area of a penetrating ulcer that has evolved to a large pseudoanerysm. The Annals of Thoracic Surgery 2007 83, S835-S841DOI: (10.1016/j.athoracsur.2006.11.019) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 (A) Survival of patients with penetrating aortic ulcer managed medically at Mayo Clinic has been superior to that of patients treated surgically. (B) As a consequence, the institutional practice has shifted to favor nonoperative management. (Open bars = total cases; shaded bars = surgically treated; solid bars = operative mortality.) The Annals of Thoracic Surgery 2007 83, S835-S841DOI: (10.1016/j.athoracsur.2006.11.019) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions