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Eur J Cardiothorac Surg 1999;16:414-417
© 1999 Elsevier Science NL

Intramural hematoma of the thoracic aorta in octogenarians: is non operation justified?

^a Department of Vascular Surgery, Medical School, Federico II, University, Naples, Italy
^b Department of Thoracic Surgery, Medical School, Federico II, University, Naples, Italy
^c Department of Radiology, Medical School, Federico II, University, Naples, Italy

Corresponding author. Present address: Viale Letizia 2, 80131 Naples, Italy. Tel.: +39-81-746-2630; fax: +39-81-545-2893

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Discussion and conclusions References

 
Objective: The prognostic factors and treatment options for thoracic aortic intramural hematoma are controversial. The purpose of this study was to determine the most suitable treatment of this condition in very elderly patients. Methods: In a review of the world literature, eight octogenarians with thoracic aortic intramural hematoma were found; to these the three cases reported here must be added. The descending thoracic aorta was involved in eight cases and the ascending/arch in three. Results: In spite of patients’ poor general conditions, the medical treatment group showed survival rates of 85.7% (descending) and 66.6% (ascending/arch), respectively. Conclusion: Extensive atherosclerotic changes of the aortic wall in the elderly, combined with control of hypertension, may probably prevent thoracic aortic intramural hematoma from progressing to dissection, with a favourable outcome. An earlier and more accurate preoperative diagnosis by modern diagnostic techniques, including spiral computed tomography (CT), as were performed in our own patients, will allow optimal treatment and increased patient survival.

Key Words: Aorta, thoracic • Hematoma • Diagnostic imaging • Treatment • Prognosis • Elderly patient

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Discussion and conclusions References

 
The classification, natural course and management of intramural hematoma (IMH) of the thoracic aorta are controversial issues as clinical and radiological evidence overlaps with findings with aortic dissection or penetrating ulcer. Patients presenting with symptoms of acute aortic dissection are diagnosed IMH if intimal tear or deeply penetrating ulcer are excluded.

Several investigations [1–3] have shown, as in classic aortic dissection, that higher survival rates are obtained with early surgical repair of IMH involving the ascending aorta and/or aortic arch, while anti-hypertensive medical treatment may be indicated in those patients where the uncomplicated lesion is located in the descending thoracic aorta. Because of the poor clinical experience, the optimal treatment and long-term prognosis of elderly patients with IMH have not been defined. In this paper three cases of thoracic aortic IMH in conservatively treated high-risk octogenarians are reported and the literature reviewed.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Discussion and conclusions References

 
2.1. Case 1
An obese 84-year-old woman was admitted with a 1-week history of persistent radiating interscapular back pain. Past medical history included poorly controlled hypertension, insulin-dependent diabetes and a myocardial infarction.

Blood pressure was 230/120 mmHg and bilateral peripheral pulses were consistent. On admission, chest X-ray showed a prominent superior mediastinum. Spiral computed tomography (CT) of the chest identified a non-enhancing intramural hematoma (Fig. 1a) in the ascending thoracic aorta and aortic arch, with no false lumen or penetrating atherosclerotic ulcer. The absence of double lumen was confirmed by aortography. The patient required sodium nitroprusside to control her blood pressure, with resolution of pain. She was discharged on day 11 and oral treatment with nifedipine was prescribed.

View larger version (53K): [in this window] [in a new window]   Fig. 1. (a) Post-contrast thoracic spiral CT showing a thickened non opacified ascending and transverse aortic wall, with displacement of parietal calcifications (intramural hematoma). A left pleural effusion is also seen. There is no evidence of intimal tear, double lumen or penetrating atherosclerotic ulcer. (b) At 6 weeks, a reduction in size of IMH is noted while pleural effusion has disappeared. (c) At 9 months, IMH has almost completely resolved.

2.2. Case 2
An 86-year-old arteriopath presented with a sudden interscapular pain, unresponsive to nitrates. Seven years before he had undergone a major amputation of the left lower limb and had a history of hypertension and significant respiratory insufficiency.

On admission, blood pressure was 215/110 mmHg. The initial chest X-ray evaluation showed a widened upper mediastinum and bilateral lung emphysema.

Thoracic spiral CT revealed an IMH in the aortic arch, without intimal flap. Aortography confirmed the absence of false lumen with no opacification of the IMH. Pulmonary tests revealed a severe respiratory dysfunction with a 45% FEV₁. Because of his severe respiratory insufficiency, the patient was considered a poor candidate for surgical correction and treated with sublingual nifedipine and analgesics.

Chest pain gradually subsided within 1 week. He was discharged on the 19th day. Follow-up spiral CT 1 month later showed no spread of the IMH. Follow-up at 1 year showed the complete disappearance of the IMH in the involved arch segment. Twenty-five months after admission the patient was still asymptomatic.

2.3. Case 3
An 81-year-old woman was admitted following a 12-h intermittent lower thoracic and epigastric pain. She had a complicated medical history which included hypertension, renal failure and colon cancer which resulted in left colectomy. On admission, blood pressure was 190/115 mmHg.

Physical examination revealed the presence of a pulsatile abdominal mass in the epigastrium. On admission, chest X-ray showed a soft tissue density adjacent to the descending thoracic aorta and left pleural effusion.

A spiral CT scan with intravenous contrast showed nearly circular and non-opacified areas in the descending thoracic aorta (intramural haemorrhage) and a left-sided pleural effusion (Fig. 2a). A 5 cm infra-renal abdominal aortic aneurysm (AAA) without blood in the retroperitoneum was also seen. No penetrating atherosclerotic ulcer and neoplastic processes were found. Because of the patient's renal condition, aortography was not performed.

View larger version (54K): [in this window] [in a new window]   Fig. 2. (a) Thoracic spiral CT with intravenous contrast showing a non-enhancing intramural hematoma in the descending thoracic aorta; adjacent atelectasis and pleural effusion are also present. (b) At 4 weeks, partial involution of IMH and resolution of the pleural effusion are noted. (c) Spiral CT evidence of IMH complete resolution 6 months after antihypertensive treatment.

At 6 months, a repeat spiral CT revealed resolution of the IMH (Fig. 2c). Follow-up at 20 months showed that the patient was still asymptomatic.

	3. Discussion and conclusions

Top Abstract 1. Introduction 2. Material and methods 3. Discussion and conclusions References

 
Intramural hematoma differentiates from other acute syndromes of the thoracic aorta as the spontaneous bleeding is confined within the aortic wall, with no intimal tear [1,4] or penetrating atherosclerotic ulcer [5,6].

This non-communicating dissection is considered to be a self-limiting variant or a precursor of aortic dissection in those cases progressing to an extensive dissection [2,7]. The primary event has been hypothesized to be the rupture of vasa vasorum [8] or an atherosclerotic plaque [9] due to arterial hypertension, with bleeding into the media. Clinical presentation includes symptoms suggestive of aortic dissection [1].

Several imaging procedures, such as angiography, computed tomography or magnetic resonance imaging [4], transoesophageal echocardiography [2,10,11] and, more recently, intravascular ultrasonography [12] are useful for diagnosing this uncommon pathologic entity.

It has been emphasised [1–3] that successful management of patients with ascending/arch IMH requires surgery, while IMH in the descending thoracic aorta without life-threatening complications may benefit from conservative treatment. In spite of this, the choice between surgical and medical treatment in very elderly patients depends less on the IMH site than on the risk/benefit ratio, since the patient may be too weak or too ill to tolerate major surgery. Moreover, a few patients with ascending/arch IMH had a spontaneous regression after simple medical treatment [4,13]. Slightly more than 100 cases of thoracic aortic IMH have been previously reported in literature but stratification of data, according to age, IMH site, treatment, and early and late outcome have been reported only for 74 patients [1–3,11,13–15]. Overall, 11 cases of IMH in elderly patients, including the three reported here, are available for analysis (Table 1) and comparisons with younger individuals.

One patient (# 5) with ascending IMH died from aortic rupture on day 1 and another (# 4) with descending thoracic IMH died from renal failure on day 32. The remaining nine patients (81.8 %) are alive at a mean follow-up of 22.4 months (range 1–54, median 20 months). In all our three medically-treated elderly patients, spiral CT with contrast enhancement was diagnostic; repeat scans showed a clear decrease of hematoma within 4–6 weeks and a subsequent spontaneous resolution (from 6 to 12 months later).

Surprisingly, the results of our analysis indicate that, whether ascending or descending thoracic IMH was involved, the prognosis for these medically-treated elderly patient was favourable (Table 2).

Furthermore, extensive involvement of the entire aortic wall due to severe atherosclerotic disease may probably account for a more benign course of IMH in elderly patients, at variance with the outcome of ascending IMH in young patients with Marfan's syndrome [3] or other predisposing factors.

In conclusion, these data suggest that conservative management may be an appropriate and safe option in very elderly high-risk patients with either ascending/arch or descending IMH. The role of spiral CT in the initial diagnosis and follow-up imaging is strongly valued. However, further evaluations on a larger series of patients are necessary to establish treatment options in this selected group of patients.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Discussion and conclusions References

 

1. Robbins R.C., Mc Manus R.P., Mitchell R.S., Latter D.R., Moon M.R., Olinger G.N., Miller D.C. Management of patients with intramural hematoma of the thoracic aorta. Circulation 1993;88(Suppl II):1-10.
2. Mohr-Kahaly S., Erbel R., Kearney P., Puth M., Meyer J. Aortic intramural hemorrhage visualized by transesophageal echocardiography: findings and prognostic implications. J Am Coll Cardiol 1994;23:658-664.[Abstract]
3. Nienaber C.A., von Kodolitsch Y., Petersen B., Loose R., Helmchen U., Haverich A., Spielmann R.P. Intramural hemorrhage of the thoracic aorta. Diagnostic and therapeutic implications. Circulation 1995;92:1465-1473.[Abstract/Free Full Text]
4. Yamada T., Tada S., Harada J. Aortic dissection without intimal rupture: diagnosis with MR imaging and CT. Radiology 1988;168:347-352.[Abstract/Free Full Text]
5. Stanson A.M., Kazmier F.J., Hollier L.H., Edwards W.D., Pairolero P.C., Sheedy P.F., Joyce J.W., Johnson M.C. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1986;1:15-23.[Medline]
6. Harris J.A., Bis K.G., Glover J.L., Bendick P.J., Shetty A., Brown W. Penetrating atherosclerotic ulcers of the aorta. J Vasc Surg 1994;19:90-99.[Medline]
7. Zotz R.J., Erbel R., Meyer J. Noncommunicating intramural hematoma: an indication of developing aortic dissection?. J Am Soc Echocardiogr 1991;4:636-638.[Medline]
8. Gore I. Pathogenesis of dissecting aneurysm of the aorta. Arch Pathol Lab Med 1952;53:142-153.
9. Hirst A.E., Johns V.J., Kime S.W. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37:217-279.[Medline]
10. Mohr-Kahaly S., Erbel R., Puth M., Zotz R., Meyer J. Aortic intramural hematoma visualized by transesophageal echocardiography. Circulation 1991;84(Suppl II):128.
11. Keren A., Kim C.B., Hu B.S., Eyngorina I., Billingham M.E., Mitchell S.R., Miller D.C., Popp R.L., Schnittger I. Accuracy of biplane and multiplane transesophageal echocardiography in diagnosis of typical acute aortic dissection and intramural hematoma. J Am Coll Cardiol 1996;28:627-636.[Abstract]
12. Alfonsa F., Goicolea J., Aragoncillo P., Hernandez R., Macaya C. Diagnosis of aortic intramural hematoma by intravascular ultrasound imaging. Am J Cardiol 1995;76:735-738.[Medline]
13. Rapezzi C., Caporale R., Traini A.M., Fattori R., Gavelli G., Magnani B. Aortic dissection without intimal laceration: a case report and review of the problem. Cardiologia 1993;38:331-336.[Medline]
14. Lui R.C., Menkis A.H., Mc Kenzie F.N. Aortic dissection without intimal rupture: diagnosis and management. Ann Thorac Surg 1992;53:886-888.[Abstract]
15. Muluk S.C., Kaufman J.A., Torchiana D.F., Gertler J.P., Cambria R.P. Diagnosis and treatment of thoracic aortic intramural hematoma. J Vasc Surg 1996;24:1022-1029.[Medline]

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