Intramural hematoma of the thoracic aorta

Intramural Hematoma of the Thoracic Aorta: A Single Institution 12 Year Experience

OBJECTIVE

The natural history and management of intramural hematoma (IMH) varies significantly worldwide. In this retrospective analysis of our institutional database, we report long-term results from medical and surgical management of types A and B IMH.

METHODS

CT scan reports completed at our tertiary care hospital from July 2007 to July 2020 were used to identify patients with IMH with thickness >7mm. Those with IMH directly related to trauma, previous aortic surgery, penetrating atheromatous ulcer, dissection flap, iatrogenic source, or who never received any treatment for IMH at the time of presentation were excluded.

RESULTS

A total of 54 patients with IMH met inclusion and exclusion criteria. Twenty-four presented with Stanford type A: 10 were initially managed surgically and 14 were initially managed medically. Two patients in the medical group crossed over to surgery. Thirty patients presented with type B IMH and were initially managed medically, with three eventually receiving surgical intervention. In-hospital survival was 90% for type A IMH treated surgically, 93% for type A IMH treated medically, and 97% for type B IMH treated medically. At last follow-up imaging of medically managed patients, 36% of type A IMH and 31% of type B IMH patients had complete resolution of IMH at 3.7 and 31.5 months respectively, without operative intervention. Development of aortic aneurysm at the site of previous IMH was seen in 18% (2/11) and 12% (3/26) for the type A medical and type B medical cohorts; the overall rate of aortic aneurysm formation in the region of IMH or in another segment was 50%. There was no difference in long-term survival between the three cohorts at a mean follow up of 22.8 months.

CONCLUSION

There appears to be a role for medical treatment with anti-impulse therapy in appropriately selected patients with type A IMH. These patients must be followed closely clinically and radiographically for signs of deterioration in the short- and long-term phases of their care. They can achieve similar long-term survival compared with surgically treated type A IMH and medically treated type B IMH patients using this algorithm but may require late surgical intervention, especially for aneurysmal disease.

Emergency Stent-Graft Placement for Impending Rupture of the Descending Thoracic Aorta

Purpose:

To present initial experience with emergent stent-graft placement for impending rupture of the descending thoracic aorta.

Case Reports:

Intramural hematoma (IMH) of the descending thoracic aorta was diagnosed by transesophageal echocardiography and computed tomography in 3 patients with acute onset of severe thoracic pain. Because of signs of impending rupture, e.g., pleural effusion, sustained pain, or transadventitial bleeding, the patients underwent emergency stent-graft placement, which was successful in all cases. No procedure-related complications were observed. Follow-up to 18 months has revealed no evidence of endoleak, and all patients remain free of symptoms.

Conclusions:

Emergency stent-graft placement may be a promising alternative to conventional surgery in patients with impending aortic rupture due to IMH.

Advances in the diagnosis of acute aortic syndromes: Role of imaging techniques

Aortic diseases include a wide range of pathological conditions: aortic aneurysms, pseudoaneurysms, acute aortic syndromes, atherosclerotic and inflammatory conditions, genetic diseases and congenital anomalies. Acute aortic syndromes have acute onset and may be life-threatening. They include aortic dissection, intramural haematoma, penetrating aortic ulcer and traumatic aortic injury. Pain is the common denominator to all acute aortic syndromes. Pain occurs regardless of age, gender and other associated clinical conditions. In this review, we deal with the main findings in the clinical setting and the most recent indications for diagnostic imaging, which are aimed to start an appropriate treatment and improve the short- and long-term prognosis of these patients.

Midterm results of type B intramural hematoma endovascular treatment

BACKGROUND

Recently, intramural hematoma (IMH) has been characterized as a rare variant of aortic dissection, falling within the acute aortic syndromes (AAS). Although aortic endovascular treatment seems to provide good results, no consensus has been established regarding the optimal management of IMH affecting the descending thoracic aorta (IMH B). The aim of this study was to assess long-term clinical and morphological results of IMH B treated with a stent graft.

METHODS

Between 2002 and 2013, 15 of the 423 (3.5%) consecutive patients with AAS were found to have IMH B. During follow-up, complications related to IMH B were observed in 10 patients, including 5 during the acute period (<14 days). Surgical indications were ulcerations, refractory pain, aneurysm evolution, aortic rupture, and pleural effusion. An endovascular approach was taken for all forms with suitable anatomy.

RESULTS

Technical success rate was 100%, with complete exclusion of lesions of the descending thoracic aorta in all cases treated with a stent graft. No neurological complications or deaths occurred within the first 30 postoperative days, nor at the end of the mean follow-up of 46 months (1-137 months). After the aortic stent graft, partial or complete regression of the hematoma was observed in all cases.

CONCLUSIONS

IMH B is most often a progressive disease requiring long-term monitoring. In case of complications, stent-graft treatment of the descending thoracic aorta can be performed successfully in most cases. This procedure appears to be a safe technique that provides very good long-term results, with favorable remodeling of the aorta.

Treatment patterns and their outcomes of acute aortic intramural hematoma in real world: multicenter registry for aortic intramural hematoma

Background

Intramural hematoma of the aorta (IMH), a variant of classic aortic dissection, shows very dynamic process in the early phase. The aim of this study is to evaluate clinical outcomes of patients with acute aortic IMH from real world registry data.

Methods

We analyzed 165 consecutive patients with acute IMH from five medical centers in Korea. All patients were divided into two groups; type A (n = 61, 37.0%) and type B (n = 104, 63.0%) according to the Stanford classification. Clinical outcomes and morphological evolution by CT were analyzed for 2 years.

Results

Most of the patients (77.0% of type A and 99.0% of type B, P < 0.001) were treated medically during their initial hospitalization. There were no significant differences in in-hospital mortality (4.9% vs. 2.9%, P = 0.671) and 2-year mortality (13.1% vs. 11.5%, P = 0.765) between two groups. During the 2-year follow up period, progression to aortic dissection (18.0% vs. 6.7%, P = 0.037) and surgical treatment (29.5% vs. 2.9%, P < 0.001) were higher in type A. For the type A patients, there were no significant difference in in-hospital mortality (7.1% of surgery vs. 4.3% of medical, P = 0.428) and 2-year mortality (7.1% of surgery vs. 14.9% of medical, P = 0.450) in terms of initial treatment strategy.

Conclusion

For real world practice in Korea, most of IMH patients were treated medically at presentation and showed favorable outcomes. Thus, even in type A acute IMH, early medical treatment with alternative surgical conversion for selected, complicated cases would be a favorable treatment option.

Acute aortic syndrome: CT findings

Acute aortic syndrome (AAS) is a constellation of potentially life-threatening acute aortic diseases. The spectrum includes penetrating atherosclerotic ulcer, intramural haematoma, dissection, and unstable thoracic aneurysm. AAS cannot be reliably diagnosed clinically and multidetector computed tomography (MDCT) has revolutionized the diagnosis and management of this group of conditions in the acute setting due to its availability, speed, and accuracy. The purpose of this review is to illustrate key MDCT findings of AAS. Imaging techniques, radiological findings, and common pitfalls are also discussed.

Acute type A aortic dissection: surgical intervention for all: PRO

Acute aortic dissection remains the most common of all aortic catastrophes and is associated with significant morbidity and mortality. Urgent surgical intervention should be considered in all patients with acute type A aortic dissection. Immediate repair is performed for those who are hypotensive due to rupture and tamponade and who exhibit malperfusion of the coronary, cerebrovascular, visceral, or peripheral arterial systems. Selective delayed management with eventual repair may be assumed in patients with type A intramural hematoma and in those with coma (potential neurologic devastation), assuming that neurologic status improves. Urgent repair should not be precluded in patients presenting with active stroke, older age, and previous cardiac surgery. Ultimately, each patient should be individualized and the decision to intervene left to the surgeon.

CT and MRI in diseases of the aorta

OBJECTIVE

This review focuses on the role of CT and MRI in the diagnosis, follow-up, and surgical planning of aortic aneurysms and acute aortic syndromes, including aortic dissection, intramural hematoma, and penetrating aortic ulcer. It also provides a systematic approach to the definition, causes, natural history, and imaging principles of these diseases.

CONCLUSION

An understanding of the pathophysiology, natural history, and imaging features is the key to successful diagnosis and appropriate management of patients with these aortic diseases.

Acute Type A Intramural Hematoma

Background— Management of acute type A intramural hematoma (IMH) remains controversial, varying from immediate surgery to medical management only. Conversion to typical dissection remains a concern. We analyzed our experience managing acute type A IMH.

Methods and Results— Between October 1999 and May 2008, 251 patients with acute type A aortic dissection were treated, including 36 (14.3%) with type A IMH. Seven IMH patients (19%) were repaired immediately, 28 (80%) managed initially with optimal medical management and eventual repair and 1 (3%) with medical management only. End points analyzed were early mortality and conversion to typical dissection (flow in the false lumen of the ascending aorta). Time (hours) from onset of symptoms defined initiation of IMH. Early mortality for acute type A IMH was 8.3% (3/36): 14.3% (1/7) with immediate repair and 7.1% (2/28) when optimal medical management with eventual repair was undertaken ( P =0.69). The 1 medically managed Asian patient survived with resolution of the IMH. Conversion to type A IMH to typical dissection occurred in 33% (12/36) of cases. No conversions were observed within 72 hours. Aortic diameter did not predict conversion. In actuarial analysis among the initially medically managed group with eventual repair, the hazard conversion to typical dissection increased significantly at 8 days from the onset of symptoms ( P <0.05).

Conclusions— Despite optimal medical management, conversion of type A IMH to typical dissection still remains a concern, with the most significant risk beyond 8 days. In our patient population, timely surgical repair is recommended.

International Heterogeneity in Diagnostic Frequency and Clinical Outcomes of Ascending Aortic Intramural Hematoma

BACKGROUND

Differing diagnostic frequencies and management strategies for intramural hematoma (IMH) have been described in North American (NA)/European and Japanese/Korean studies.

METHODS

All publications including type-A aortic IMH were reviewed for details on patient demographics, treatment strategy, and clinical outcomes. Publications were stratified by the geographic region (NA/Europe or Japan/Korea).

RESULTS

IMH, as a percentage of aortic dissection, occurs more frequently in Japan/Korea versus NA/Europe (31.7% vs 10.9%, P < .0001). The proportion of patients treated with early medical therapy is greater in Japanese/Korean studies (77.9% vs 48.8% in NA/Europe, P < .0001). However, the overall mortality is significantly lower in Japan/Korea compared with NA/Europe (9.4% vs 20.6%, odds ratio = 2.80, P = .003) in part because of the lower mortality with early medical therapy (7.8% vs 33.3%, P < .0001).

CONCLUSION

There is significant international heterogeneity in the diagnosis and clinical outcomes of ascending IMH. IMH is diagnosed more frequently and has better overall outcomes in Japan/Korea.

CT Analysis of the Growth Rate of Aortic Diameter Affected by Acute Type B Intramural Hematoma

OBJECTIVE

The purpose of this study was to evaluate the growth rate of aortic diameter affected by acute type B intramural hematoma and the factors that influence its enlargement.

MATERIALS AND METHODS

Fifty-four patients were entered into this study, and regular follow-up CT studies (mean +/- SD, 46.9 +/- 27.2 months; range, 5-136 months) were performed. The affected aortas and iliac arteries were divided into five segments. A total of 127 segments were evaluated (aortic arch, n = 47; descending thoracic aorta, n = 51; suprarenal abdominal aorta, n = 24; infrarenal abdominal aorta, n = 3; and iliac artery, n = 2). The growth rate of each segment was obtained on CT. The factors influencing increase in the diameter and growth rate--age, sex, diabetes mellitus, atherosclerotic disease, history of smoking 20 years, chronic renal failure, blood pressure, initial diameter of the lumen, the presence of blood flow in the false lumen--were evaluated by univariate analysis and a multivariate logistic regression model.

RESULTS

Twenty (37.0%) of 54 patients had one or more segments that increased in size during the follow-up period. Of a total of 127 segments, 35 (27.6%) increased in size, and for all, the mean growth rate was -0.5 +/- 2.9 mm/year. This negative growth rate represents shrinkage. The mean growth rates within the first year and after 1 year from onset were -2.2 +/- 5.7 and 0.4 +/- 3.2 mm/year, respectively, and a significant difference was observed between them (p < 0.0001). An initial diameter of 40 mm or greater and the presence of blood flow in the false lumen were significant risk factors for an increase in the diameter, as confirmed by univariate and multivariate analyses.

CONCLUSION

In patients with type B intramural hematoma, the affected aortas did not show a high incidence of enlargement during the follow-up period, but the affected aortas tended to increase in size after 1 year from onset. An initial diameter of 40 mm or greater and the presence of blood flow in the false lumen were important risk factors for enlargement during the follow-up period.

Aortic intramural hematoma: a case report of spontaneous resolution

Aortic intramural hematoma is an acute aortic syndrome caused by hemorrhage within the aortic wall and characterized by the absence of an intimal tear and false lumen, which are the main features of classic aortic dissection. Although surgical intervention represents the standard management of type A aortic intramural hematoma, the possibility of treating some patients with medical therapy associated with serial imaging evaluations at follow-up has recently been demonstrated.

Long-term outcome of type B aortic intramural hematoma: comparison with classic aortic dissection treated by the same therapeutic strategy

BACKGROUND

The long-term clinical course and therapeutic strategy of patients with type B aortic intramural hematoma (IMH) are not completely known. The purpose of this study was to clarify long-term prognosis of patients with type B IMH by comparison with type B classic aortic dissection (AD).

METHODS

Clinical data were compared retrospectively between 37 patients with acute type B IMH (IMH group) and 69 patients with acute type B AD (AD group). Our therapeutic strategy for all patients was medical therapy with frequent follow-up imaging studies and timed surgical repair in cases with progression.

RESULTS

Initially, medical therapy was selected for 104 of 106 (98%) patients. In two patients of the AD group, immediate surgical treatment was performed because of aortic rupture. As for complications, no significant difference was seen between the two groups. There was no significant difference in the incidence of the total number of deaths; early death, late death, or causes of deaths. The actuarial survival rates for the IMH group at 1, 2, 5, and 10 years were 97 +/- 3, 97 +/- 3, 85 +/- 9, and 85 +/- 9%, respectively; the values were 96 +/- 1, 96 +/- 1, 89 +/- 4, and 71 +/- 9%, for the AD group. The actuarial survival rates of the two groups were not significantly different from each other (p = 0.398).

CONCLUSIONS

Patients with type B IMH have similar long-term prognosis to patients with type B AD. Medical therapy with frequent follow-up imaging studies and timed surgical repair in cases with progression can be a rational therapeutic strategy in patients with type B IMH.

Long-term prognosis of patients with type B aortic intramural hematoma

BACKGROUND

The long-term clinical course of patients with type B aortic intramural hematoma (IMH) and predictors for progression remains unknown. The difference of aortic pathology may have a different impact on clinical course compared with classic aortic dissection (AD). The purpose of this study was to investigate long-term clinical course and predictors of progression in patients with type B IMH.

METHODS AND RESULTS

Clinical data were compared retrospectively between 53 patients with acute type B IMH (IMH group) and 57 patients with acute type B AD (AD group). All patients were treated initially with medical therapy. Two patients in IMH group and 14 patients in AD group underwent surgical repair because of aortic enlargement. The in-hospital mortality rate in IMH group was significantly lower than that in AD group (0% and 14%, P=0.006). Mean follow-up periods were 53+/-43 months, which revealed 3 and 5 late deaths, respectively. Eleven patients with IMH showed progression (development of aortic dissection or aortic enlargement) in follow-up imaging study. The actuarial survival rates in IMH group were 100%, 97%, and 97% at 1, 2, and 5 years, which were significantly higher than those in AD group (83%, 79%, and 79%) (P=0.009). Multivariate analysis identified age >70 years and new appearance of an ulcerlike projection as the strongest predictors of progression in patients with IMH.

CONCLUSIONS

Patients with type B IMH have better long-term prognosis than patients with AD. Older age and appearance of an ulcerlike projection are predictive for progression in patients with type B IMH.

Long-term follow-up of aortic intramural hematoma: predictors of outcome

BACKGROUND

Aortic intramural hematoma (IMH) evolves very dynamically in the short-term to regression, dissection, or aortic rupture. The aim of the present study was to assess the long-term clinical and morphological evolution of medically treated IMH.

METHODS AND RESULTS

Fifty of 68 consecutive patients with aortic IMH monitored clinically and by imaging techniques at 3, 6, and 12 months and annually thereafter were prospectively studied. Mean follow-up was 45+/-31 months. In the first 6 months, total IMH regression was observed in 14 and progression to aortic dissection in 18 patients; in 14 of these, the dissection was localized, and 12 later developed pseudoaneurysm. At the end of follow-up, the IMH had regressed completely without dilatation in 17 patients (34%), progressed to classical dissection in 6 (12%), evolved to fusiform aneurysm in 11 (22%), evolved to saccular aneurysm in 4 (8%), and evolved to pseudoaneurysm in 12 (24%). Evolution to dissection was related to echolucency (P<0.02) and to longitudinal extension of IMH (P<0.01). Multivariate analysis showed an independent association between regression and smaller maximum aortic diameter and between aneurysm formation and atherosclerotic ulcerated plaque and absence of echolucent areas in IMH.

CONCLUSIONS

The most frequent long-term evolution of IMH is to aortic aneurysm or pseudoaneurysm. Complete regression without changes in aorta size is observed in one third of cases, and progression to classical dissection is less common. A normal aortic diameter in the acute phase is the best predictor of IMH regression without complications, and absence of echolucent areas and atherosclerotic ulcerated plaque are associated with evolution to aortic aneurysm.

Intramural hematoma of the aorta: predictors of progression to dissection and rupture

BACKGROUND

Aortic intramural hematoma (IMH) is a variant of overt aortic dissection. The predictors of progression of IMH to dissection and rupture are still unknown, and strategies for management are not established.

METHODS AND RESULTS

A multicenter study was conducted comprising 66 patients with IMH and hospital admission <or=48 hours after onset of initial symptoms. Among these, progression to aortic dissection or rupture occurred in 30 (45%) and death occurred in 13 (20%) patients within 30 days. Late progression was noted in 14 (21%) and death in 11 (17%) patients, yielding a 1-, 2-, and 5-year survival of 76%, 73%, and 43%, respectively. In a set of 9 variables, multivariate analysis identified IMH location in the ascending aorta (type A; P=0.02) and moderately ectatic aortic diameters (49+/-13 mm with progression versus 57+/-16 mm without progression; P=0.03) as independent predictors of early progression. In type A IMH, early mortality was 8% with swift surgery versus 55% without surgery (P=0.004). The risk of late progression of IMH was independently associated with age at index diagnosis (P=0.01) and absence of beta-blocker therapy during follow-up (P=0.03). Kaplan-Meier analysis confirmed improved 1-year survival of IMH with beta-blocker therapy (95% versus 67% without beta-blockers; P=0.004).

CONCLUSIONS

Regardless of aortic diameter, IMH of the ascending aorta (type A) is at high risk for early progression, and, thus, undelayed surgical repair should be performed. Moreover, oral beta-blocker therapy may improve long-term prognosis of IMH independent of anatomical location.

Clinical, diagnostic, and management perspectives of aortic dissection

The incidence of aortic dissection ranges from 5 to 30 cases per million people per year, depending on the prevalence of risk factors in the study population. Although the disease is uncommon, its outcome is frequently fatal, and many patients with aortic dissection die before presentation to the hospital or prior to diagnosis. While pain is the most common symptom of aortic dissection, more than one-third of patients may develop a myriad of symptoms secondary to the involvement of the organ systems. Physical findings may be absent or, if present, could be suggestive of a diverse range of other conditions. Keeping a high clinical index of suspicion is mandatory for the accurate and rapid diagnosis of aortic dissection. CT scanning, MRI, and transesophageal echocardiography are all fairly accurate modalities that are used to diagnose aortic dissection, but each is fraught with certain limitations. The choice of the diagnostic modality depends, to a great extent, on the availability and expertise at the given institution. The management of aortic dissection has consisted of aggressive antihypertensive treatment, when associated with systemic hypertension, and surgery. Recently, endovascular stent placement has been used for the treatment of aortic dissection in select patient populations, but the experience is limited. The technique could be an option for patients who are poor surgical candidates, or in whom the risk of complications is gravely high, especially so in the patients with distal dissections. The clinical, diagnostic, and management perspectives on aortic dissection and its variants, aortic intramural hematoma and atherosclerotic aortic ulcer, are reviewed.

Analysis of predictive factors for progression of type B aortic intramural hematoma with computed tomography

PURPOSE

For patients with Stanford type B aortic intramural hematoma (IMH), medical treatment is usually selected. However, the outcomes of patients with type B IMH are not completely understood, and some cases can have fatal complications develop or surgical treatment necessitated. The purpose of this study was to investigate predictors of progression of the affected aorta in patients with type B IMH with initial computed tomography (CT) images.

METHODS

Thirty-five patients with type B IMH were studied with serial CT images. Initially, medical therapy was selected for all patients. CT findings of the affected aorta were evaluated on admission and at follow-up. We divided the patients into two groups (progression group or regression group) on the basis of CT findings and investigated predictors of progression of the affected aorta with initial CT images.

RESULTS

We defined 15 patients who showed increased maximum aortic diameter (n = 14), increased maximum aortic wall thickness (n = 3), progression to overt dissection (n = 4), or rupture of the aortic wall (n = 2) during the follow-up period as the progression group. The other 20 patients, who all showed decreased maximum aortic wall and aortic wall thickness, were defined as the regression group. In the maximum aortic diameter, an optimal cutoff value of 40 mm resulted in positive predictive and negative predictive values of 86.7% and 90.0%, respectively. Both a maximum aortic diameter of 40 mm or more (P =.0011) and a maximum aortic wall thickness of 10 mm or more (P =.0009) were shown to be significantly predictive of the progression with Cox regression analysis.

CONCLUSION

Maximum aortic diameter and maximum aortic wall thickness on initial CT images are predictive for progression of the affected aorta in patients with type B IMH. For type B IMH with a maximum aortic diameter of 40 mm or more or a maximum aortic wall thickness of 10 mm or more, careful follow-up studies must be required.

Penetrating atherosclerotic ulcers of the aorta

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.

Clinical features and prognosis of acute aortic intramural hemorrhage compared with those of acute aortic dissection: a single center experience

The clinical manifestations and natural history of acute aortic intramural hemorrhage are not well characterized. Therefore, we have evaluated the differences in the clinical features and prognosis between acute intramural hemorrhage and acute classic aortic dissection. One hundred two consecutive patients with acute aortic syndrome were diagnosed between November 1994 and May 1999. The clinical features, treatment modalities and survival of these patients were analyzed. Thirty one of the 102 patients (30%) had intramural hemorrhage and 71 (70%) had aortic dissection. Patients with intramural hemorrhage were older than those with aortic dissection (mean ages 67 and 55 years, respectively) (p < 0.001), and intramural hemorrhage showed a lower proportion of type A than did aortic dissection (32% and 58%, respectively) (p = 0.018). The incidence of severe complications was significantly lower in patients with intramural hemorrhage than in those with aortic dissection (19% and 27%, respectively) (p < 0.001). Mean follow-up duration was 23.1+/-16.0 months. The overall death rate for patients with intramural hemorrhage (2 / 31; 6%) tended to be lower than those with aortic dissection (14 / 71; 20%) (p = 0.104). The Stanford classification and treatment modalities were not correlated with death. Late follow-up imaging studies in intramural hemorrhage showed partial to complete resolution of intramural hematoma (9 / 15; 60%). In this study, intramural hemorrhage was fairly common, more frequent among older patients, had a lower proportion of type A, and showed a lower incidence of severe complications and a more favorable prognosis in terms of mortality, than aortic dissection.

Meta-analysis of 143 reported cases of aortic intramural hematoma

Aortic intramural hematoma (IMH) is a clinical condition that has still not been completely defined. We conducted a meta-analysis of reported cases and analyzed the demographic profiles, imaging modalities, pathologic sites, and treatment strategies in relation to outcome in 143 patients with IMH. We performed an English language search of Medline for manuscripts with the keywords "aortic diseases," "aorta AND hematoma," and "intramural hematoma." Data from 143 reported cases were extracted. IMH of the aorta has a reported incidence of 5% to 20% among patients with acute aortic syndromes and a mortality rate of 21%. Most patients were men (61%) and median age was 68 years (range 15 to 88). Hypertension was a predisposing factor in 53% of the patients. Most patients had chest and/or back pain (80%). Transesophageal echocardiography, computer tomographic scan, or magnetic resonance imaging may be effectively used to diagnose this condition. There is no difference in the overall mortality rates in Stanford type A versus type B patients. Patients with Stanford type A IMH who underwent surgery, compared with those who underwent medical management, had a significantly better prognosis (14% vs 36% mortality, respectively, p < 0.02). Patients in Stanford group A who received medical treatment had a higher mortality rate than those in group B who received medical treatment (36% vs 14% mortality respectively, p < 0.02). In type B patients, medical and surgical outcomes were similar.

Surgical techniques. Ascending aorta

Aneurysm and dissection are the most common diseases affecting the ascending aorta. Graft replacement of the ascending aorta is a straightforward cardiovascular procedure with excellent early and late results. When aneurysm or dissection extends into the aortic sinuses or arch, management becomes more complex and may entail replacement of the aortic root, aortic valve, or a portion of the aortic arch using hypothermic circulatory arrest. The optimal root prosthesis depends on several patient- and procedure-related variables. Valve-sparing procedures confer many long-term advantages and should be considered in all cases where the aortic valve leaflets are normal. The Ross procedure, although ideally suited for isolated aortic valve disease in young patients, may be applicable to some patients with combined aortic valve and ascending aortic disease, unless there is evidence of a systemic connective tissue disorder.

Spontaneous progression of ascending aortic intramural hematoma to Stanford type A dissection fortuitously witnessed during an MR examination

Aortic intramural hematoma may occur as a primary event (spontaneous dissection without intimal flap) or secondary to a penetrating atherosclerotic ulcer. The management of intramural hematoma of the ascending aorta is somewhat controversial because of limited published data, but some centers advocate early surgical intervention. We describe a patient with an intramural hematoma of the ascending aorta that progressed to a classic communicating dissection during an MR examination. This case graphically demonstrates the potential instability of patients with intramural hematoma of the ascending aorta.

Aortic pain: the renaissance of cardiovascular pain and the detection of aortopathy

Our 19th century predecessors considered the aorta as a source of cardiovascular pain associated with inflammatory aortitis, arterial hypertension, aortic aneurysms, aortic dissection, and aortic valve disease. However, during the 20th century epidemic of coronary artery disease clinicians became concerned with the syndromes associated with myocardial ischemia and infarction, relegating aortic pain syndromes to the role of a differential, "rule out", or diagnosis of exclusion rather than a primary diagnosis. We re-focus attention on a more global approach to cardiovascular pain, approaching thoracic aortic pain syndromes as primary diagnoses, while considering the dynamics and various stages of development of aortic pain syndromes, set within the clinical environment in which these syndromes arise. The central role of aortopathy is our underlying theme since the detection and clinical recognition of aortopathic disorders provide the template for identification of the population at risk for aortic pain syndromes. Clinical history, pedigree development, phenotype recognition, analysis of the elastic properties of the aorta, use of the wide range of sophisticated imaging techniques, and phenotype-genotype correlations provide the bases for the recognition, diagnosis, and management of aortopathy within the clinical setting. A futuristic anticipatory approach towards the diagnosis of aortopathy is outlined with emphasis on earlier recognition and informed clinical management ultimately leading to prevention of the acute and dynamic aortic complications.