Aortic intramural haematoma: natural history and predictive factors for complications

Natural history and long-term outcomes of medically managed Type B intramural hematoma

OBJECTIVE

Type B intramural hematoma (IMH) is often managed medically, yet may progress to dissection, aneurysmal dilation, or rupture. The aim of this study was to report the natural history of medically managed Type B IMH, and factors associated with progression.

METHODS

We reviewed patients with medically managed Type B IMH between January 1995 to December 2022 at a single center. Any patients with immediate surgical or endovascular intervention were excluded. Demographic profiles, comorbidities, imaging, and follow-up details were reviewed. Patients were divided into two groups: Group 1 had isolated IMH, and Group 2 had IMH along with aneurysm or dissection at the time of presentation. On follow-up, progression was defined as degeneration to aneurysm/dissection or increase in the thickness of IMH in Group 1. In Group 2, progression was an increase in the size of aneurysm or development of new dissection.

RESULTS

Of 104 patients with Type B IMH during the study period, 92 were medically managed. The median age was 77 years, and 45 (48.9%) were females. Comorbidities included hypertension (83.7%), hypercholesterolemia (44.6%), and active smoking (47.8%). Mean Society for Vascular Surger comorbidity score was 6.3. Mean IMH thickness and aortic diameter at presentation were 8.9 mm and 38.3 mm, respectively. Median follow-up was 55 months. Overall survival at 1 year and 5 years was 85.8% and 61.9%, respectively. During follow-up, 19 patients (20.7%) required intervention, more common in Group 2 (Group 1, 8/66; 12.3% vs Group 2, 11/26; 42.3%; P = .001). This resulted in higher freedom from intervention in Group 1 at 1 year (93.5% vs 62.7%) and 5 years (87.5% vs 51.1%; P < .001). Indication for intervention was dissection (n = 4), aneurysm (n = 12), and progression of IMH (n = 3). In Group 1, progression was seen in 25 (37.9%), three (4.5%) remained stable, 29 (43.9%) had complete resolution of IMH, and nine patients were lost to follow-up. In Group 2, 11 patients (42.3%) had progression, seven (26.9%) remained stable, and eight were lost to follow-up. IMH thickness at presentation >7.2 mm is associated with both increased odds of progression (odds ratio, 3.3; 95% confidence interval, 1.2-11.1; P = .03) and intervention (odds ratio, 5.5; 95% confidence interval, 1.3-36.9; P = .03) during the follow-up.

CONCLUSIONS

Although many patients with Type B IMH managed medically stabilize or regress, progression or need for intervention can occur in up to 40% of cases. This is associated with the presence of aneurysm, dissection, and IMH thickness. Long-term follow-up is mandatory as late interventions occur, particularly for higher risk patients.

Initial Triage and Management of Patients with Acute Aortic Syndromes

The acute aortic syndromes (AAS) are life-threatening vascular compromises within the aortic wall. These include aortic dissection (AD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), and blunt traumatic thoracic aortic injury (BTTAI). While patients classically present with chest pain, the presentation may be highly variable. Timely diagnosis is critical to initiate definitive treatment and maximize chances of survival. In high-risk patients, treatment should begin immediately, even while diagnostic evaluation proceeds. The mainstay of medical therapy is acute reduction of heart rate and blood pressure. Surgical intervention is often required but is informed by patient anatomy and extent of vascular compromise.

Management of penetrating aortic ulcer and intramural hematoma in the thoracic aorta

Acute aortic syndrome is a broad clinical entity that encompasses several pathologies. Aortic dissection is a well-studied disorder, but the other most prominent disorders within the scope of acute aortic syndrome, penetrating aortic ulcer and intramural hematoma, are more nebulous in terms of their pathophysiology and treatment strategies. While patient risk factors, presenting symptoms, and medical and surgical management strategies are similar to those of aortic dissection, there are indeed nuanced differences unique to penetrating aortic ulcer and intramural hematoma that surgeons and acute care providers must consider while managing patients with these diagnoses. The aim of this review is to summarize patient demographics, pathophysiology, workup, and treatment strategies that are unique to penetrating aortic ulcer and intramural hematoma.

Management of spontaneous isolated intramural hematoma of the superior mesenteric artery: a single-center experience

PURPOSE

To investigate the clinical course and optimal management for spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA).

METHODS

From January 2015 to October 2020, a total of 31 consecutive patients with SIHSMA were included in this study. The demographics, clinical features, treatment details, imaging information, and outcomes were reviewed.

RESULTS

There were 24 males and 7 females, with a mean age of 54.9 years (SD 6.9 years). Seven patients (7/31, 23%) were associated with ulcer-like projection (ULP), one patient (1/31, 3%) with intramural blood pool (IBP), and the remaining twenty-three patients (23/31, 74%) had no ULP or IBP. All patients were initially managed conservatively and underwent a median follow-up of 25.5 months (IQR 14.5, 39.9), which showed 3 patients (3/31, 10%) subsequently underwent stenting (2 within 7 days and 1 after 1.5 months), 1 patient (1/31, 3%) progressed to a localized dissection 7 months later but remained stable and asymptomatic until the time of writing, and the remaining patients (27/31, 87%) had no progression. In the present cohort, the overall survival was 100% (31/31). The free-from progression and stenting rate under conservative treatment was 87% (27/31). The invasive intervention rate was 10% (3/31). The natural complete regression rate of IMH in patients without ULP was higher than those with ULP (91% [21/23] vs. 29% [2/7], p = .003).

CONCLUSION

The majority of patients with SIHSMA can be managed conservatively. Patients with ULP seemed to have a lower IMH regression rate than those without ULP.

Endovascular repair of penetrating aortic ulcers: Indications and single-center mid-term results

BACKGROUND

Although endovascular repair is used to treat penetrating aortic ulcers (PAUs), the indications for endovascular repair in PAUs remain controversial. The current study evaluated the mid-term results of endovascular repair for PAUs and further explored the endovascular indications for PAUs.

METHODS

We retrospectively reviewed the clinical data of patients who were diagnosed with PAUs and underwent endovascular repair in our department from October 2018 to August 2020. Endovascular indication included persistent or recurring symptoms, a maximum diameter of the PAU of greater than 20 mm, a maximum depth of the PAU of greater than 10 mm, an increase in the diameter of the aorta at the ulcer of greater than 10 mm annually, and multiple ulcers at the same or adjacent level of the aorta. Patient characteristics, anatomical parameters of the PAU, characteristics of endovascular repair and follow-up data were analyzed.

RESULTS

Fifteen patients were included in the study. Three patients had PAUs in the aortic arch, 6 PAUs were in the descending thoracic aorta, 4 PAUs were in the abdominal aorta, and 2 PAUS were in the descending thoracic and abdominal aortas. The average age was 70.60±8.27 years. Eight patients were symptomatic. The average depth of the PAUs was 7.32±2.74 mm, and the average diameter was 15.03±6.10 mm. The average operation time was 95.60±33.11 min. Postoperative hospital stay was 3.33±0.61 days. A left subclavian artery chimney stent was implanted in 3 aortic arch cases and 1 occluded case without adverse symptoms during the follow-up period. A bifurcated stent graft was placed in 3 abdominal aorta cases and exhibited good patency during the follow-up period. The duration of follow-up ranged from 3 to 24 months. The follow-up results showed that all PAUs were treated satisfactorily by endovascular repair, and no endoleaks or stent graft-related complications occurred.

CONCLUSIONS

Endovascular repair is a safe and effective treatment for PAUs, and it may be safely performed in elderly patients and patients with comorbidities. The endovascular indications for PAUs must be further studied and optimized.

Intramural hematoma and penetrating ulcer in the descending aorta: differences and similarities

Acute aortic syndromes include a variety of overlapping clinical and anatomic diseases. Intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and aortic dissection can occur as isolated processes or can be found in association. All these entities are potentially life threatening, so prompt diagnosis and treatment is of paramount importance. IMH and PAU affect patients with atherosclerotic risk factors and are located in the descending aorta in 60-70% of cases. IMH diagnosis can be correctly made in most cases. Aortic ulcer is a morphologic entity which comprises several entities-the differential diagnosis includes PAU, focal intimal disruptions (FID) in the context of IMH evolution and ulcerated atherosclerotic plaque. The pathophysiologic mechanism, evolution and prognosis differ somewhat between these entities. However, most PAU are diagnosed incidentally outside the acute phase. Persistent pain despite medical treatment, hemodynamic instability, maximum aortic diameter (MAD) >55 mm, significant periaortic hemorrhage and FID in acute phase of IMH are predictors of acute-phase mortality. In these cases, TEVAR or open surgery should be considered. In non-complicated IMH or PAU, without significant aortic enlargement, strict control of cardiovascular risk factors and frequent follow-up imaging appears to be a safe management strategy.

Hit by the wave: a case of painful Horner's and intramural haematoma of the carotid

Carotid artery dissection from rupture of the vasa vasorum is under-recognised. We report the case of a 60-year-old woman presenting to our hospital with a 2-week history of right-sided headache, neck pain, unequal pupils and ptosis after being hit by a wave on the beach. She was diagnosed with painful Horner's syndrome. MR angiogram revealed dissection of the right internal carotid artery with an intramural haematoma without an intimal flap. A diagnosis of carotid artery dissection from rupture of the vasa vasorum was made. Initial antithrombotic (aspirin and clexane) were stopped as she was deemed a low stroke risk with no signs of ischaemia on MR brain. Her clinical course was uneventful with resolution of the intramural haematoma seen on repeat MR angiogram.

Acute Aortic Syndromes: Update in Current Medical Management

OPINION STATEMENT

Advances in medical therapy and non-surgical percutaneous options to manage the specter of acute aortic syndromes have improved both patient morbidity and mortality. There are key features in the patient history and initial exam which physicians should be attuned to in order to diagnose acute aortic syndromes such as aortic dissection, penetrating aortic ulcer, and intramural hematoma. Once recognized, early initiation of the appropriate pharmacologic therapy is important, and further appreciating the limitations of such therapy before considering a surgical approach is critical to improve patient outcomes. For the undifferentiated patient with acute aortic dissection presenting to facilities who do not routinely manage this condition, adding pharmacologic agents in the correct sequence assures the best chance for a satisfactory outcome.

The Acute Abdominal Aorta

Acute disorders of the abdominal aorta are potentially lethal conditions that require prompt evaluation and treatment. Computed tomography (CT) is the primary imaging method for evaluating these conditions because of its availability and speed. Volumetric CT acquisition with multiplanar reconstruction and three-dimensional analysis is now the standard technique for evaluating the aorta. MR imaging may be useful for select applications in stable patients in whom rupture has been excluded. Imaging is indispensable for diagnosis and treatment planning, because management has shifted toward endoluminal repair. Acute abdominal aortic conditions most commonly are complications of aneurysms and atherosclerosis.

The role of multidetector-row CT in the diagnosis, classification and management of acute aortic syndrome

The term "acute aortic syndrome" (AAS) encompasses several non-traumatic life-threatening pathologies of the thoracic aorta presenting in patients with a similar clinical profile. These include aortic dissection, intramural haematoma and penetrating atherosclerotic ulcers. These different pathological entities can be indistinguishable on clinical grounds alone and may be confused with other causes of chest pain, including myocardial infarction. Multidetector-row CT (MDCT) is the current modality of choice for imaging AAS with a sensitivity and specificity approaching 100%. Early diagnosis and accurate radiological classification is associated with improved clinical outcomes in AAS. We review the characteristic radiological features of the different pathologies that encompass AAS and highlight the vital role of MDCT in determining the management of these life-threatening conditions.

Multi-detector computed tomography in the diagnosis and management of acute aortic syndromes

Acute aortic syndrome (AAS) is a spectrum of conditions, which may ultimately progress to potentially life-threatening aortic rupture. This syndrome encompasses aortic dissection (AD), intramural haematoma, penetrating atherosclerotic ulcer and unstable thoracic aortic aneurysms. Multi-detector CT (MDCT) is crucial for the diagnosis of AAS, especially in the emergency setting due to its speed, accuracy and ready availability. This review attends to the value of appropriate imaging protocols in obtaining good quality images that can permit a confident diagnosis of AAS. AD is the most commonly encountered AAS and also the one with maximum potential to cause catastrophic outcome if not diagnosed and managed promptly. Hence, this review briefly addresses certain relevant clinical perspectives on this condition. Differentiating the false from the true lumen in AD is often essential; a spectrum of CT findings, e.g., “beak sign”, aortic “cobwebs” that allows such differentiation have been described with explicit illustrations. The value of non enhanced CT scans, especially useful in the diagnosis of an intramural hematoma has also been illustrated. Overlap in the clinical and imaging features of the various conditions presenting as AAS is not unusual. However, on most instances MDCT enables the right diagnosis. On select occasions MRI or trans-esophageal echocardiography may be required as a problem solving tool.

Acute aortic syndrome mimicking intramural hematoma with hemopericardium

We report a case of acute aortic syndrome in a 64-year-old man who presented with chest pain and hypotension. His electrocardiogram and cardiac troponins were normal. Computed tomography showed hemopericardium of 2.4 cm, but no aortic intimal tear. At surgery, the portion of the aorta affected by adventitial hemorrhage was replaced with a Dacron graft. A nonpenetrating ulcerated plaque was also observed. Massive bleeding through the chest drains with hypotension required emergency reoperation in the intensive care unit. The patient was discharged home on postoperative day 11.

A catastrophic cause of chest pain

Chest pain can be a manifestation of aortic pathology and must be considered in any patient with a history of chest trauma, hypertension, atherosclerosis, connective tissue disorder and/or radiographically abnormal aortic contours. Acute intramural haematoma can resemble acute myocardial infarction and can be life-threatening if not correctly diagnosed. Electrocardiogram (ECG) must be carried out in all patients as it helps distinguish acute myocardial infarction (for which antiplatelets and anticoagulants may be life-saving) from intramural haematoma (for which these drugs may be detrimental). Other imaging modalities may be considered depending upon the clinical situation.

Management of acute aortic syndromes

Acute aortic syndrome (AAS) is a modern term to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges. These conditions include aortic dissection, intramural haematoma (IMH), and penetrating atherosclerotic ulcer (PAU and aortic rupture); trauma to the aorta with intimal laceration may also be considered. The common denominator of AAS is disruption of the media layer of the aorta with bleeding within IMH, along the aortic media resulting in separation of the layers of the aorta (dissection), or transmurally through the wall in the case of ruptured PAU or trauma. Population-based studies suggest that the incidence of acute dissection ranges from 2 to 3.5 cases per 100 000 person-years; hypertension and a variety of genetic disorders with altered connective tissues are the most prevalent risk conditions. Patients with AAS often present in a similar fashion, regardless of the underlying condition of dissection, IMH, PAU, or contained aortic rupture. Pain is the most commonly presenting symptom of acute aortic dissection and should prompt immediate attention including diagnostic imaging modalities (such as multislice computed tomography, transoesophageal ultrasound, or magnetic resonance imaging). Prognosis is clearly related to undelayed diagnosis and appropriate surgical repair in the case of proximal involvement of the aorta; affection of distal segments of the aorta may call for individualized therapeutic approaches favouring endovascular in the presence of malperfusion or imminent rupture, or medical management.

Endovascular treatment of thoracic dissection

Type A aortic dissection remains fatal if untreated. Although classical medical therapy for type B dissection is considered the therapy of choice in uncomplicated cases, the paradigm is changing as greater experience is accrued with endovascular treatments and technical advances improve the long-term outlook. Diagnosis is also becoming more sophisticated, allowing greater appreciation of the anatomy of dissections and improving the knowledge base as their natural history is assessed.

Intramural haematoma and penetrating aortic ulcer -outcome and treatment modalities: Report of four cases

Introduction. Intramural haematoma (IMH) and penetrating aortic ulcers (PAU) are the frequent cause of acute aortic syndrome that is disclosed with a rising frequency due to the development of new diagnostic methods. Different symptoms contribute to clinical misdiagnosis, while changeable locations and unpersuasive diameter can lead the radiologists to underestimate such changes. The outcome of PAU and IMH differs, and for the time being there are no data on prognostic factors. The diversity of symptoms and disease course is presented in four cases with different manifestations, treatment and outcome. Outline of Cases. Two patients with IMH were treated conservatively due to the process extensiveness and its morphology. One patient had a complete restitution, while the other had progression of the disease. Other two patients with PAU were treated by surgery (stent graft implantation) according to the morphology and diameter of the aorta. Conclusion. IMH and PAU should be suspected in patients with unclear clinical presentation (back and abdominal pains). Although outcome and complications of these diseases are well known, their incidence has not been fully studied. Endovascular treatment is less invasive and followed by a potentially lower rate of complications. However, usage of this method is justifiable only in patients with associated complications.

Intramural haematoma of the thoracic aorta: who's to be alerted the cardiologist or the cardiac surgeon?

This review article is written so as to present the pathophysiology, the symptomatology and the ways of diagnosis and treatment of a rather rare aortic disease called Intra-Mural Haematoma (IMH). Intramural haematoma is a quite uncommon but potentially lethal aortic disease that can strike as a primary occurrence in hypertensive and atherosclerotic patients to whom there is spontaneous bleeding from vasa vasorum into the aortic wall (media) or less frequently, as the evolution of a penetrating atherosclerotic ulcer (PAU). IMH displays a typical of dissection progress, and could be considered as a precursor of classic aortic dissection. IMH enfeebles the aortic wall and may progress to either outward rupture of the aorta or inward disruption of the intima layer, which ultimately results in aortic dissection. Chest and back acute penetrating pain is the most commonly noticed symptom at patients with IMH. Apart from a transesophageal echocardiography (TEE), a tomographic imaging such as a chest computed tomography (CT), a magnetic resonance (MRI) and most lately a multy detector computed tomography (MDCT) can ensure a quick and accurate diagnosis of IMH. Similar to type A and B aortic dissection, surgery is indicated at patients with type-A IMH, as well as at patients with a persistent and/or recurrent pain. For any other patient (with type-B IMH without an incessant pain and/or without complications), medical treatment is suggested, as applied in the case of aortic dissection. The outcome of IMH in ascending aorta (type A) appears favourable after immediate (emergent or urgent) surgical intervention, but according to international bibliography patients with IMH of the descending aorta (type B) show similar mortality rates to those being subjected to conservative medical or surgical treatment. Endovascular surgery and stent-graft placement is currently indicated in type B IMH.

Endovascular stent-graft management of aortic intramural hematomas

PURPOSE

To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH).

MATERIALS AND METHODS

From 2000 to 2006, 15 patients (mean age, 67 years; range, 54-83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6-72 months).

RESULTS

The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%.

CONCLUSIONS

Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.

Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD)

Acute aortic dissection is a rare but deadly disease first described over 200 years ago by the physician to the late King George II on necropsy. Over the ensuing 2 centuries, the understanding of the pathophysiology, presentation, diagnosis, treatment and follow-up has matured. In an effort to understand the contemporary treatment of this disease, the International Registry of Acute Aortic Dissection (IRAD) has enrolled over 2000 patients over the past 12 years. In this article we summarize the key lessons learned from this multi-national registry of patients presenting with acute aortic dissection.

Clinical and anatomical characteristics of subtle-discrete dissection of the ascending aorta

Subtle or discrete (class 3 in the classification of the European Society of Cardiology) dissection is the most neglected variant of aortic dissection. This study was conducted to define the clinical manifestations, diagnostic findings, and outcomes of subtle or discrete dissection involving the ascending aorta. The clinical and surgical records, preoperative studies, and outcomes of 109 consecutive patients with ascending aortic dissection observed from 1995 to 2005 were reviewed. Eight patients (7.3%) had discrete dissection. Five patients presented with acute anterior chest pain, 2 with abdominal pain, and 4 with syncope. The mean diameter of the ascending aorta was 44 +/- 8.8 mm. The intimal tears were located in all patients on the posterior aspect of the ascending aorta 1 to 40 mm above the left coronary ostium; its length varied from 2.8 to 12.3 mm. Preoperative aortography, magnetic resonance imaging, and computed tomography could not identify the discrete intimal tears. Transesophageal echocardiography provided unique diagnostic information on (1) subtle intimal discontinuity, (2) circumscribed intramural hematoma, and (3) discrete pericardial fluid around the dissected aorta. Six patients underwent emergency surgery on the basis of echocardiographic findings, and they were all alive at follow-up. Compared with patients with classic aortic dissection, those with discrete dissection had lower operative mortality (0% vs 26%, p = 0.11), shorter hospital stay (7.2 +/- 2.8 vs 21 +/- 19 days, p = 0.01), and less frequent need for blood transfusions (0% vs 39%, p = 0.02). In conclusion, elevated clinical suspicion and detailed transesophageal echocardiographic examination are important for the early identification of discrete aortic dissection, leading to prompt surgery, shorter hospital stays, and better outcomes.

Factors associated with in-hospital mortality in patients with acute aortic syndrome involving the ascending aorta

BACKGROUND

Aortic intramural hematoma (IMH), a variant form of classic dissection (AD), is an increasingly recognized and potentially fatal entity of acute aortic syndrome (AAS). We sought to assess the real impact of increased recognition of IMH on mortality of AAS involving the ascending aorta.

METHODS

We evaluated 186 consecutive patients with AAS involving the ascending aorta (57.0+/-13.5 years, 95 females) admitted between January 1993 and March 2003.

RESULTS

Final diagnosis was AD in 135 patients and IMH in 51 (27%). Patients with AD were younger (54.0+/-13 vs. 65.6+/-10.7 years, p<0.05) and surgery was more frequently performed (82% vs. 31%, p<0.001). Overall in-hospital mortality was 16% (30/186); both total mortality (19% vs. 8%, p=0.059) and mortality without surgery (71% vs. 9%, p<0.001) was higher in AD. Logistic regression identified the following presenting variables as predictors of mortality: AD (OR 53.0; 95% CI, 6.6-425.4; p<0.001), confusion/coma (OR 20.1; 95% CI, 3.8-107.8; p<0.001), tamponade (OR 5.3; 95% CI, 1.2-24.3; p=0.031), heart failure (OR 8.1; 95% CI, 1.1-61.0; p=0.043), and medical treatment only (OR 17.6; 95% CI, 4.6-67.6, p<0.001). Tamponade was more prevalent in IMH (25% vs. 11%, p=0.038), and was a predictor of higher mortality in both groups.

CONCLUSION

IMH comprises of significant proportion of AAS involving the ascending aorta and is an independent variable associated with lower mortality despite lower frequency of surgery. Treatment option including optimal timing of surgery can be individualized based on underlying disease entity of AAS and some clinical features at the initial presentation.

[Thoracic aortic dissection revealed by systemic cholesterol embolism]

Systemic cholesterol embolism is a rare complication of atherosclerosis, and has various presentations. Arterial catheterisms are a common cause. However, the association with an aortic dissection has been exceptionally reported. We report the observation of a 70 year-old man, with coronary artery disease, hypertension, diabetes and dyslipidemia. Six months before hospitalization, a coronary angioplasty was performed due to recurrent angina. The association of purpuric lesions on the feet, with acute renal failure confirmed cholesterol embolism syndrome. Transoesophageal echocardiography showed a dissection of the descending thoracic aorta associated with complex atheroma. The evolution was marked by the pulpar necrosis of a toe and by a worsening of the renal failure, requiring definitive hemodialysis. Further echographic control highlighted the rupture of the intimal veil of the dissection. Cholesterol embolism syndrome may reveal an aortic dissection in patients without thoracic symptoms. In such cases, transoesophageal echocardiography is a useful and non-invasive examination.

Periaortic lymphoma as a mimic of posttraumatic intramural hematoma

Computed tomography (CT) of an 87-year-old man who presented to the emergency department with chest pain after a motor vehicle collision demonstrated multiple broken ribs and a thoracic periaortic soft tissue mass which was high density on precontrast images and enhanced postcontrast. The scan also demonstrated a mass encircling the left ureter and masses in the axilla and pelvis. The enhancement of the periaortic lesion and the presence of the additional soft tissue masses suggested lymphoma as opposed to intramural hematoma (IMH). The diagnosis of follicular B-cell lymphoma was rapidly confirmed with fluorodeoxyglucose-positron emission tomography/CT and excisional biopsy of the axillary lymph node. While this is an atypical presentation, lymphoma and other extravascular pathology must be considered in the evaluation of a periaortic high attenuation mass seen on CT.

Acute aortic syndrome: pathology and therapeutic strategies

Acute aortic syndrome (AAS) describes the acute presentation of patients with characteristic "aortic pain" caused by one of several life threatening thoracic aortic pathologies. These include aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer, aneurysmal leak, and traumatic transection. AAS heralds imminent aortic rupture. Highlighting acute aortic pathology as an AAS is therefore important to encourage prompt recognition of this condition and avoid diagnostic delays. The management of AAS remains a therapeutic challenge. The traditional surgical approach to acute "type B" (descending thoracic) aortic pathology is unsatisfactory with high morbidity and mortality. Endovascular aortic stent grafts now represent an alternative minimally invasive approach in these patients who are often poor surgical candidates. Studies show endovascular repair to be technically feasible with fewer complications. This review discusses AAS pathology and in particular assesses the current role for endovascular aortic repair in its treatment.