1. Angioclub Case Series: Aortic Pathology Candace L. White MA, MD Mount Sinai Medical Center of Florida

2. Patient Presentation 79 y male, retired urologist CC: acute onset of substernal chest pain HPI: patient was watching the superbowl when he experienced acute onset and progressive substernal chest pain with radiation to back MHx: CAD, severe HTN, noted medication non-compliance

3. Workup/Clinical Integration ER EKG Cardiac Enzymes CT Chest w +w/o Cardiology ICU admission for BP control TEE Cardiothoracic Surgery Interdisciplinary discussion of treatment options with patient/family Interventional Radiology Intervention

4. Non-Invasive Imaging Intramural Hematoma of the Ascending Thoracic Aorta and Arch (Type A) *no dissection flap identified

5. Non-Invasive Imaging Penetrating Ulcer of the Descending Thoracic Aorta

6. Diagnosis CT demonstrates Type A intramural hematoma involving the ascending aorta and aortic arch with suspect point of origin at a penetrating ulcer immediately distal to the L subclavian artery origin TEE confirmed intramural hematoma without distinct dissection flap, lack of involvement of the coronary arteries or cardiac sinuses, and absence of pericardial effusion

7. Management Options  Medical Management strict BP control  Surgical Management immediate vs delayed repair of ascending aorta +/- repair of transverse aortic arch  Endovascular Management endovascular stent graft

8. Review of Literature  Vast majority of studies report: significantly high rate of progression of Type A IMH to aortic dissection, aneurysm, or rupture significantly increased mortality with medical management compared to surgical management  Few studies report: resolution of IMH without progression to more malignant processes, in a select population  TWO studies report: successful management of Type A IMH with endovascular approach studies consist of 4 and 8 patients

9. Definitive Treatment Patient refused open repair Interdisciplinary decision was made to intervene with endovascular approach to prevent progression of disease process TEVAR using 40mm x 40mm x 15cm endograft placed just distal to the L subclavian artery origin to cover the penetrating ulcer, thought to be the origin of the IMH

10. Follow-up Imaging at 3 months post TEVAR demonstrates complete resolution of Type A IMH without evidence of progression to dissection flap, aneurysm, or rupture

11. References Monnin-Bares V, Thony F, Rodiere M, et al. Endovascular stent-graft management of aortic intramural hematomas. J Vasc Interv Radiol. 2009; 20(6): 713-721. Grimm M, Loewe C, Gottardi R, et al. Novel insights into the mechanisms and treatment of intramural hematoma affecting the entire thoracic aorta. Ann Thorac Surg. 2008; 86: 453-456. Estrera A, Miller C, Lee T, et al. Acute type a intramural hematoma: analysis of current management strategy. Circulation 2009; 120: S287-S291. Maraj R, Rerkpattanapipat P, Jacobs LE, et al. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol. 2000; 86: 664-668. Sueyoshi E, Matsuoka Y, Imada T, et al. New development of an ulcerlike projection in an aortic intramural hematoma: CT evaluation. Radiology. 2002; 224: 536-541. Ganaha F, Miller DC, Sugimoto K, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002; 106: 342-348. Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008; 85: S1-S41.