Clinical Analysis of Acute Type A Intramural Hematoma: Comparison Between Two Different Pathophysiological Types Kunihide Nakamura, MD, PhD, Toshio Onitsuka,

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Clinical Analysis of Acute Type A Intramural Hematoma: Comparison Between Two Different Pathophysiological Types Kunihide Nakamura, MD, PhD, Toshio Onitsuka, MD, PhD, Mitsuhiro Yano, MD, PhD, Yoshikazu Yano, MD, PhD, Masakazu Matsuyama, MD, Kazushi Kojima, MD, PhD The Annals of Thoracic Surgery Volume 81, Issue 5, Pages 1587-1592 (May 2006) DOI: 10.1016/j.athoracsur.2005.12.068 Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Computed tomography images from a patient in the non–penetrating atherosclerotic ulcer group (a 65-year-old woman with severe chest pain). She received only medical treatment thoroughly. (a) Initial computed tomography scan at the onset demonstrates nonopacified crescentic areas along the wall of the ascending aorta and the descending aorta. The diameter of the ascending aorta is 49 mm. (b) There was no calcification in the transverse aortic wall. (c) One month later, the nonopacified crescentic area has decreased in size, and the ascending aortic diameter is 47 mm. (d) Five years later, the nonopacified crescentic area has totally absorbed, and the ascending aortic diameter is 42 mm. The Annals of Thoracic Surgery 2006 81, 1587-1592DOI: (10.1016/j.athoracsur.2005.12.068) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Computed tomography images from a patient in the penetrating atherosclerotic ulcer group (a 65-year-old man with severe chest pain and hypotension). Emergent operation was performed, and no intimal tear was found in the ascending aorta and the aortic arch. Pathology specimens showed medial hemorrhage with moderate atherosclerosis, and there was no evidence of cystic medial necrosis or degeneration. (a) A nonopacified crescentic area can be observed in the ascending aorta, and the descending aorta has multiple atheromatous ulcers. (b) Multiple calcifications are visible in the wall of the aortic arch. (c) Hemopericardium is evident, and calcification is visible in the descending aortic wall. (d) A contrast-filled ulcer is seen in the abdominal aorta. The Annals of Thoracic Surgery 2006 81, 1587-1592DOI: (10.1016/j.athoracsur.2005.12.068) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Ulcer lesions (arrows) in patients of the non-penetrating atherosclerotic ulcer group. (a) In a 60-year-old woman, ascending aortic replacement was performed 48 days after the onset because of progression to type A double-barreled aortic dissection. (b) In a 71-year-old woman, ascending and transverse aorta replacement was performed 41 days after the onset because of progression to type A double-barreled aortic dissection. (c) A 54-year-old woman received only medical treatment, and the intramural hematoma was absorbed and disappeared. (d) In an 81-year-old woman, urgent operation was performed because of dilatation of ascending aorta (60 mm) and pericardial effusion. Pathology specimens showed medial dissection with cystic medial degeneration. The Annals of Thoracic Surgery 2006 81, 1587-1592DOI: (10.1016/j.athoracsur.2005.12.068) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Comparison of actuarial survival curves in patients with acute type A classic aortic dissection (open circles [n = 54]) and acute type A noncommunicating aortic dissection (solid circles [n = 28]; p = 0.0284). The Annals of Thoracic Surgery 2006 81, 1587-1592DOI: (10.1016/j.athoracsur.2005.12.068) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions