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Eur J Cardiothorac Surg 2001;19:170-173
© 2001 Elsevier Science NL

Intramural hematoma of the aorta: diagnosis and treatment

Department of Cardio-thoracic Surgery, V.le Morgagni 85, 50134 Florence, Italy

Received 12 November 1999; received in revised form 16 November 2000; accepted 5 December 2000.

Corresponding author. Tel.: +39-055-427-7215; fax: +39-055-427-7702
e-mail: amper30{at}hotmail.com

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion 4. Conclusions References

 
Objective: Increasing use of modern high-resolution imaging techniques yields to describe very early stages of aortic pathology which, if left untreated, may lead to overt aortic dissection. One typical example is aortic intramural hematoma (IMH) with a limited number of cases described in the literature and uncertainties still existing about the most appropriate treatment. Purpose of our study is to report our experience in the evaluation and treatment of IMHs. Methods: From 1991 to 1999 175 patients were conveyed to our centre for aortic dissection; in nine of them diagnosis of acute IMH was performed. Results: Diagnosis was obtained by means of conventional CT scan of the chest. All the patients underwent surgery, one patient died (11%). At the follow-up (mean 31 months) eight patients were alive and well and did not require any other cardiac surgery. Conclusions: The possibility to progress to overt aortic dissection may explain the need to an early diagnosis in the treatment of acute IMHs. Immediate surgical treatment is, in our experience, the preferred therapeutic option.

Key Words: Intramural hematoma • Acute aortic dissection

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion 4. Conclusions References

 
Intramural hematoma (IMH) of the aorta is a pathological pattern whose description has become more and more frequent due to the improvement of diagnostic techniques and in which the most appropriate treatment is still debated [1,2].

To our knowledge less than 200 cases, mostly involving the descending aorta, are described in the literature; such limited number may explain present uncertainties about pathogenesis and treatment [3–8].

The importance of an early recognition of this entity does not account only for its evolution but also for a better understanding of the initiating mechanism of acute aortic dissection and therefore to assess newer therapeutic strategies [1,2,9].

In this study we report our experience with acute IMH, stressing the indication to an early surgical treatment.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion 4. Conclusions References

 
Between 1991 and 1999, 175 patients were admitted to our centre with indication of acute aortic dissection; among them nine patients (three males and six females; mean age 69.3 years, range 56–82 years) suffered from IMH, attested by the absence of intimal tear and communication between false and true lumen.

The characteristics of these patients are summarised in Table 1.

2.1. Diagnostic evaluation
Transesophageal echocardiographic examination (TEE) showed in four cases dilatation of ascending aorta, with involvement in one case also of the arch and descending aorta; in the patient admitted in cardiogenic shock a large pericardial effusion with signs of cardiac tamponade was observed. Doppler evaluation revealed mild aortic insufficiency in five cases; severe in one.

Diagnosis of IMH was obtained by means of CT scan of the chest, (Somatorn HIQ Siemens) revealing dilation of aorta (mean 53 mm) and the peculiar pattern of wall thickening of the aorta, hyperdense to the direct evaluation and not enhanced after intravenous injection of contrast medium, in the absence of intimal tear (Fig. 1). In one patient operated as an emergency because of cardiac tamponade, the diagnosis was made directly at the table.

View larger version (87K): [in this window] [in a new window]   Fig. 1. Imaging of TMH by CT of chest (direct and after injection of contrast medium). The figure shows wall thickening of the aorta which appears hyperdense to the direct evaluation and did not enhance after intravenous injection of contrast medium.

2.2. Surgical technique
All the patients with IMH of the ascending aorta underwent emergency surgery with cardiopulmonary bypass (CPB) and deep hypothermia, in addition to the conventional monitoring a catheter was inserted through the internal jugular vein in the jugular bulb for evaluation of oxygen saturation of the blood effluent from the brain. Cardiac arrest was achieved with cold cristalloid cardioplegia: circulatory arrest was instituted at 16–18° when brain effluent blood oxygen saturation reached 100% and remained stable. Aorta was then resected and cleaved layers glued together in order to restore the integrity of the aortic wall. Then open distal anastomosis was performed, CPB reinstituted and rewarming started; during this time proximal anastomosis was performed. Coexisting mild aortic insufficiency due to progression of the hematoma towards the heart was treated conservatively with resuspension of the cusps. In one patient showing sclero-calcific degenerative disease of the leaflets, the valve was replaced.

2.3. Results
Table 2 shows CPB, aortic cross clamping, cardiac arrest times and associate procedures. In hospital deaths were one out of nine, occurring in the patient arrived in cardiogenic shock because of cardiac tamponade. Neither permanent nor transient neurological defects were evident in any patient. In one case postoperative respiratory insufficiency ensued and prolonged mechanical ventilation was needed. Median in hospital stay was 10.3 days.

	3. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion 4. Conclusions References

 
Acute aortic dissection, if not treated, carriers a mortality rate of 8% at 6 h, 21% at 24 h and 50% at 2 days [10]. This trend outlines the importance of an early diagnosis with an accurate evaluation of the initial symptoms, followed by a prompt intervention.

In autoptic studies IMHs represent the 5–13% of the total number of acute aortic dissections [3,10,11]. Nevertheless, clinical studies, which employ modern imaging techniques (CT, TEE, MRI) report a frequency variable from 10 to 41% of all the cases of acute aortic dissections [4,5,7,8,12–16]. Moreover, as it is clear from the literature, the clinical evolution of IMHs is similar to that of classical acute aortic dissection [2]. Our experience, numerically limited if we consider the absolute number, but relatively important if we consider the total number of cases reported in the literature, is in agreement with the data of other authors.

In IMHs the most appropriate diagnostic approach is not aortography, which is always negative because of lack of communication between the false and the true lumen. [2,5,17].

TEE represents a diagnostic tool rapid and easy to perform; nevertheless the diagnosis of IMHs can be a challenge to TEE because crescentic wall thickening of the aorta may be non-specific if typical clinical symptoms are not related and characterisation of wall thickening is not attempted [18]. In fact IMH must be differentiated from atherosclerosis and laminated thrombus in aneurysm. Moreover with current ultrasound technology it may not be possible to distinguish IMH from aortic dissection with thrombosed false lumen [18].

In our experience CT scan is an accurate way to diagnose IMH. It is able to evidence regional wall thickening and to differentiate it from intramural thrombosis.

Some authors outline the importance of MRI to identify IMHs; this technique is also able to age the process by the analysis of the formation of metahemoglobin in the collected blood [8].

Some different opinions exist about the treatment of IMHs of the ascending aorta, depending on time of onset, suggesting medical treatment for chronic and subacute dissections of the descending aorta. In our series all the patients underwent surgery, treating IMH as emergencies. In fact, according to Nienaber, IMHs of the ascending aorta evolve rapidly towards true dissection with its well known complications [8]. Moreover, early surgical intervention appears to be easier to perform because aortic wall yet non-dissected results stronger offering a better tissue for the suture. The choice of deep hypothermia e circulatory arrest is related to our experience in the treatment of classical dissecting aneursysms of the ascending aorta: invaginating the aortic prosthesis into the aortic arch under direct vision anastornosis can be managed easily and in a short time.

The behaviour with IMHs of the descending aorta is different: many authors suggest for them an initial medical therapy with a close follow-up of the evolution of the haematoma with frequent clinical and instrumental evaluations needed to exclude progression of the lesion [7].

Positively, in our experience, the patient with IMH of the descending aorta was initially treated medically, but after 2 weeks, was readmitted with chest pain and the CT scan showed progression of the lesion cranially to involve the ascending aorta, making emergency surgery essential.

	4. Conclusions

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion 4. Conclusions References

 
The capacity of progressing to overt aortic dissection may explain the need of an early diagnosis in the treatment of IMHs. An improvement in techniques of rapid execution may allow the identification of a greater number of initial aortic dissections, susceptible of a definitive surgical treatment. Because of the good results obtained by our and other centres [3–8,19] with early surgery it is our firm belief that such cases must be treated in the same way as overt aortic dissection: the earlier the surgery better the results.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion 4. Conclusions References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Giuseppe Vaccari Giancarlo Calamai Avio Maria Perna Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vaccari, G. Articles by Perna, A. M. Search for Related Content PubMed PubMed Citation Articles by Vaccari, G. Articles by Perna, A. M. Related Collections Great vessels