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Dev R, Gitanjali K, Anshuman D. Demystifying penetrating atherosclerotic ulcer of aorta: unrealised tyrant of senile aortic changes. J Cardiovasc Thorac Res 2021; 13:1-14. [PMID: 33815696 PMCID: PMC8007901 DOI: 10.34172/jcvtr.2021.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/09/2021] [Indexed: 12/14/2022] Open
Abstract
This review article describes demographic features, comorbidities, clinical and imaging findings, prognosis, and treatment strategies in penetrating atherosclerotic ulcer (PAU) and closely related entities using google scholar web search. PAU is one of the manifestations of the acute aortic syndrome (AAS) spectrum. The underlying aorta invariably shows atherosclerotic changes or aneurysmal dilatation. Hypertension is the most common contributing factor, with chest or back pain being the usual manifestation. Intramural hematoma (IMH) is the second entity associated with both PAU and aortic dissection (AD), more so with the latter. Chest radiograph can show mediastinal widening, pleural, or pericardial fluid in rupture. Computed tomography angiography (CTA) is the imaging modality of choice to visualize PAU, with magnetic resonance imaging (MRI) and transoesophageal echocardiography (TEE) adding diagnostic value. Lesser-known entities of intramural blood pool (IBP), limited intimal tears (LITs), and focal intimal disruptions (FID) are also encountered. PAU can form fistulous communication with adjacent organs whereas IMH may propagate to dissection. CTA aids in defining the management, open or endovascular options in surgical candidates.
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Affiliation(s)
- Rahul Dev
- Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Rishikesh, Uttarakhand-249203, India
| | - Khorwal Gitanjali
- Department of Anatomy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand-249203, India
| | - Darbari Anshuman
- Department of Cardiothoracic and Vascular Surgery (CTVS), All India Institute of Medical Sciences, Rishikesh, Uttarakhand-249203, India
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Jen JP, Malik A, Lewis G, Holloway B. Non-traumatic thoracic aortic emergencies: imaging diagnosis and management. Br J Hosp Med (Lond) 2020; 81:1-12. [PMID: 33135923 DOI: 10.12968/hmed.2020.0344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The major component of non-traumatic thoracic aortic emergencies is the acute aortic syndromes. These include acute aortic dissection, intramural haematoma and penetrating atherosclerotic ulcer, grouped together because they are indistinguishable clinically and highly fatal. All three entities involve disruption to the tunica intima and media and may be complicated by rupture, end-organ ischaemia or aneurysmal transformation. Early diagnosis is vital to allow timely and appropriate management. Paired unenhanced and electrocardiogram-gated computed tomography angiography of the chest, extending more distally if required, is recommended for diagnosis. Specific computed tomography features of all three entities are reviewed, with a focus on morphological features associated with complications. Those with type A pathology are usually managed with open surgery because this has a high risk of complication. Patients with uncomplicated type B pathology are usually managed with best medical therapy whereas those with complicated type B pathology are usually offered either surgery or thoracic endovascular aortic repair. The limited evidence regarding the use of thoracic endovascular aortic repair in patients with subacute uncomplicated type B pathology is briefly discussed.
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Affiliation(s)
- Jian Ping Jen
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Akif Malik
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gareth Lewis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Benjamin Holloway
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections. J Vasc Surg 2020; 71:723-747. [DOI: 10.1016/j.jvs.2019.11.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/03/2019] [Indexed: 12/11/2022]
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Lombardi JV, Hughes GC, Appoo JJ, Bavaria JE, Beck AW, Cambria RP, Charlton-Ouw K, Eslami MH, Kim KM, Leshnower BG, Maldonado T, Reece TB, Wang GJ. Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) Reporting Standards for Type B Aortic Dissections. Ann Thorac Surg 2020; 109:959-981. [PMID: 32000979 DOI: 10.1016/j.athoracsur.2019.10.005] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/15/2019] [Indexed: 01/09/2023]
Abstract
This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.
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Affiliation(s)
- Joseph V Lombardi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Cooper University Hospital, Camden, New Jersey.
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, Massachusetts
| | - Kristofer Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Karen M Kim
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Thomas Maldonado
- Division of Vascular Surgery, New York University Medical Center, New York, New York
| | - T Brett Reece
- Department of Surgery, Division of Cardiothoracic, University of Colorado, Denver, Colorado
| | - Grace J Wang
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Lee WMM, Wong OF, Fung HT. Penetrating Atherosclerotic Ulcer - an Increasingly Recognized Entity of the Acute Aortic Syndrome: Case Report and Literature Review. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790901600409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
With the advance in diagnostic radiology, penetrating atherosclerotic ulcers of the aorta become increasingly recognised in our daily practice. However, their natural history and treatment are not well defined. We report a case of penetrating atherosclerotic ulcer at the aortic arch and review the literature.
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Abstract
Rarely, penetrating atherosclerotic ulcers can rupture into the wall of the aorta, resulting in acute aortic dissection. This article describes a woman with an incidental diagnosis of type A aortic dissection secondary to a penetrating atherosclerotic ulcer of the ascending aorta. Although surgical repair of the aortic root was recommended, the patient refused treatment and left against medical advice.
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Botta L, Buttazzi K, Russo V, Parlapiano M, Gostoli V, Di Bartolomeo R, Fattori R. Endovascular repair for penetrating atherosclerotic ulcers of the descending thoracic aorta: early and mid-term results. Ann Thorac Surg 2008; 85:987-92. [PMID: 18291184 DOI: 10.1016/j.athoracsur.2007.10.079] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 10/23/2007] [Accepted: 10/24/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Penetrating atherosclerotic ulcer is an acute aortic syndrome with a high incidence of complications and rupture. Until now, no generally accepted therapeutic regimen has been established because the natural history of penetrating atherosclerotic ulcers is extremely variable. We investigated the technical feasibility and the early and mid-term results of endovascular stent graft treatment in a consecutive series of patients who had penetrating ulcers. METHODS From July 1997 to December 2006, 19 patients (14 men and 5 women) with a mean age of 71.8 +/- 7.2 years were treated for penetrating ulcers. Seven patients presented with an acute and symptomatic penetrating atherosclerotic ulcer, and in 12 patients, the ulcerative process was chronic. Clinical and imaging follow-up was performed in all patients using computed tomography or magnetic resonance imaging. RESULTS Technical success (insertion and deployment of the stent graft) was achieved in 18 of 19 cases. Neither paraplegia nor other perioperative complications occurred. Two patients treated under emergency conditions in whom the aortic syndrome was recognized after the acute onset died in the hospital (11.1%) of multiorgan failure. Follow-up has been completed in all patients, with a median time of 22 months (range, 3 to 108 months). Endoleaks occurred in 3 patients: 1 had surgical repair (5.6%), 1 leak sealed spontaneously, and 1 sealed after a second endovascular procedure. Late death occurred in 4 patients from non-aortic causes. CONCLUSIONS Endovascular stent graft repair is a low-invasive, attractive, and rational treatment option in aortic ulcers that provides satisfactory perioperative and mid-term results.
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Affiliation(s)
- Luca Botta
- Cardiac Surgery, Cardiothoracovascular Department, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
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Horiuchi K, Takatori A, Inenaga T, Ohta E, Ishii Y, Kyuwa S, Yoshikawa Y. Histopathological Studies of Aortic Dissection in Streptozotocin-Induced Diabetic APA Hamsters. Exp Anim 2005; 54:363-7. [PMID: 16093651 DOI: 10.1538/expanim.54.363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Syrian hamsters of the APA strain (APA hamsters) are known to show continuous diabetes accompanied by its complications, such as glomerulosclerosis and atherosclerosis, following a single injection of streptozotocin (SZ). Recently, we observed Stanford type B aortic dissection in three diabetic APA hamsters and histopathological analysis was performed. The histopathologic observations in the false lumen, such as proliferation of granulation tissues, neointima and pseudoneointima, corresponded to the non-thrombosed type of human aortic dissection, and blood clots of the thrombosed type were similar to the remodeling structures of aortic dissection found in human cases. Thus, this model may be useful for investigating the etiology and pathogenesis of aortic dissection accompanying diabetes mellitus in humans.
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Affiliation(s)
- Keiko Horiuchi
- Department of Biomedical Science, Graduate School of Agricultural and Life Science, The University of Tokyo, Tokyo, Japan
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Abstract
Multislice CT aortography represents a major advance in the noninvasive evaluation of thoracic aortic disease. MSTCA is rapidly becoming the preferred modality for the initial investigation of acute aortic syndromes. Although scan quality is usually excellent, special attention to various technical parameters is required to optimize image quality. Familiarity with diagnostic pitfalls and the common imaging presentations of various thoracic aortic syndromes is necessary for accurate diagnosis.
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Affiliation(s)
- Michael B Gotway
- Department of Radiology, San Francisco General Hospital, 1001 Potrero Avenue, Room 1X 55A, Box 1325, San Francisco, CA 94110, USA.
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Jain D, Gehl HB, Katus HA, Richardt G. Penetrating atherosclerotic ulcer of the ascending aorta: a delayed complication of coronary artery bypass surgery--a case report. Angiology 2003; 54:251-5. [PMID: 12678203 DOI: 10.1177/000331970305400217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 71-year-old woman, undergoing coronary angiography during preoperative evaluation for a major noncardiac surgery, was fortuitously detected as having penetrating atherosclerotic ulcer of the ascending aorta 5 years after coronary artery bypass surgery. While acute aortic dissections have been described after coronary bypass grafting, penetrating atherosclerotic ulcer of the ascending aorta as a delayed complication of bypass surgery has never been reported. The patient was treated conservatively and closely observed. A brief review of literature is also presented.
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Affiliation(s)
- Deepak Jain
- Medizinische Klinik II, Universitätsklinikum Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany.
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Crespo G, Jacobs LE, Maraj S, Garcia F, Zaeri N, Kotler MN. Penetrating aortic atherosclerotic ulcer complicated by periesophageal hematoma. J Am Soc Echocardiogr 2003; 16:182-4. [PMID: 12574746 DOI: 10.1067/mje.2003.22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Penetrating aortic atherosclerotic ulcers have been recently recognized as an entity among the acute aortic syndromes with a potentially fatal outcome. We describe the case of a patient presenting with severe chest pain who died as a result of a thoracic-aorta penetrating atherosclerotic ulcer complicated by a intramural hematoma of the esophagus and stomach, leading to exsanguination. To our knowledge this is the first case reported in the literature of such a complication from penetrating aortic atherosclerotic ulcers.
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Affiliation(s)
- Guillermo Crespo
- Division of Cardiology, Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA.
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Abstract
BACKGROUND Penetrating aortic ulcers burrow into the aortic wall and can have fatal consequences. Although they were first described as long ago as 1934 they have only recently been recognized as a distinct pathological entity. METHOD A review of the current literature was undertaken, based primarily on an English language Medline search with secondary references obtained from key articles. RESULTS Penetrating aortic ulcer is principally a disease of elderly hypertensive men. It may run a benign course or may produce complications such as aortic rupture, embolization and aneurysm formation. Presentation may be identical to that of classical aortic dissection, but the distinction is important because an ulcer may be more likely to cause rupture. CONCLUSION Open surgical repair has been the 'gold standard' of treatment but endovascular stenting is an attractive option in this group of frail patients.
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Affiliation(s)
- M Troxler
- Vascular Surgical Unit, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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Hayashi H, Matsuoka Y, Sakamoto I, Sueyoshi E, Okimoto T, Hayashi K, Matsunaga N. Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept. Radiographics 2000; 20:995-1005. [PMID: 10903689 DOI: 10.1148/radiographics.20.4.g00jl01995] [Citation(s) in RCA: 202] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Penetrating atherosclerotic ulcer is an ulcerating atherosclerotic lesion that penetrates the elastic lamina and is associated with hematoma formation within the media of the aortic wall. This pathologic condition is distinct from classic aortic dissection and aortic rupture; however, care should be taken in making the diagnosis, particularly if the disease is discovered incidentally. At computed tomography (CT), penetrating atherosclerotic ulcer manifests as focal involvement with adjacent subintimal hematoma and is often associated with aortic wall thickening or enhancement. Magnetic resonance imaging is superior to conventional CT in differentiating acute intramural hematoma from atherosclerotic plaque and chronic intraluminal thrombus and allows unenhanced multiplanar imaging. Spiral CT involves shorter examination times and allows high-quality two- and three-dimensional image reconstruction. CT angiography can demonstrate complex spatial relationships, mural abnormalities, and extraluminal pathologic conditions. Transesophageal echocardiography has been reported to be highly sensitive and specific in the differentiation of aortic disease, and intravascular ultrasonography may also be useful in this setting. Although rupture or other life-threatening complications are rare, patients with penetrating atherosclerotic ulcer must be followed up, particularly during the 1st month after onset. Surgical treatment may become necessary in cases involving evidence of intramural hematoma expansion, signs of impending rupture, inability to control pain, or blood pressure changes.
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Affiliation(s)
- H Hayashi
- Department of Radiology, Nagasaki University School of Medicine, Sakamoto, Japan
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Úlcera penetrante de aorta: una causa no descrita de hemorragia digestiva alta masiva. Med Clin (Barc) 2000. [DOI: 10.1016/s0025-7753(00)71179-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Moriyama Y, Yamamoto H, Hisatomi K, Matsumoto H, Shimokawa S, Toyohira H, Taira A. Penetrating atherosclerotic ulcers in an abdominal aortic aneurysm: report of a case. Surg Today 1998; 28:105-7. [PMID: 9505329 DOI: 10.1007/bf02483620] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We report the case of a 74-year-old man found to have an extensive intramural hematoma (IMH) in the infrarenal abdominal aorta during a follow-up imaging study performed after repair of a DeBakey type II aortic dissection with an aortic arch true aneurysm. Enhanced computed tomographic scan and angiography revealed an extensive IMH and multiple penetrating atherosclerotic ulcers in the abdominal aorta. The patient underwent a successful replacement of the affected abdominal aorta using a collagen-impregnated woven Dacron graft. Atheromatous ulcers are known to occur frequently in patients with advanced atherosclerosis. Hence, the elderly hypertensive patient, being at high risk of developing a variety of aortic disorders, requires careful follow-up imaging studies to assess the aorta on a regular basis.
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Affiliation(s)
- Y Moriyama
- Second Department of Surgery, Kagoshima University, Faculty of Medicine, Japan
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Moriyama Y, Yotsumoto G, Kuriwaki K, Watanabe S, Hisatomi K, Shimokawa S, Toyohira H, Taira A. Intramural hematoma of the thoracic aorta. Eur J Cardiothorac Surg 1998; 13:230-9. [PMID: 9628371 DOI: 10.1016/s1010-7940(97)00317-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE This study was designed to clarify the optimal treatment mode of patients with intramural hematoma (IMH) of the thoracic aorta. METHODS From 1992 through 1997, 51 patients underwent surgical repair or medical treatment of IMH of the thoracic aorta. There were 36 male and 15 female patients, aged between 49 and 79 years with a mean of 67 years. The ascending aorta and/or aortic arch was involved in 18 patients (group I), whereas the descending thoracic aorta was affected in 33 (group II). The presence of intimal disruption in IMH was confirmed in 10 of group I and 13 of group II patients. RESULTS For group I patients 13 required aortic arch repairs and the remaining 5 underwent conservative therapy including anti-hypertensive medication. Primary indications for immediate surgery were: cardiac tamponade in 5 patients, aortic dissection superimposed on IMH in 2, and persistent pain with an aortic arch aneurysm in 1, respectively. Early elective operations were done for enlarged ulcer in 3 patients and aneurysmal dilatation in 2 of which 1 had a coexisting aortic arch aneurysm. The 2-year survival rate after diagnosis was 94% with an operation-free rate of 25%. Nine of the group II patients experienced surgical intervention of which 8 had intimal disruption, 4 patients received urgent replacement of the descending thoracic aorta for massive pleural effusion and 1 had the aortic arch replaced for a coexisting aneurysm with persistent pain. All other patients underwent conservative treatment and 4 of them had to be shifted to early surgery during the initial hospitalization because of an enlarged ulcer. The 5-year survival rate in group II patients was 63% with an operation-free survival rate of 66%. CONCLUSIONS On the basis of our experience early operation is recommended for almost all patients with ascending aortic IMH, and medical therapy for those with descending aortic involvement unless complication developed. However, the presence of intimal disruption may require early surgical treatment even in the patients with descending thoracic IMH.
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Affiliation(s)
- Y Moriyama
- Second Department of Surgery, Kagoshima University, Faculty of Medicine, Sakuragaoka, Kagoshima City, Japan
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