Diagnosing Aortic Intramural Hematoma: Current Perspectives

Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

A Rare Initial Presentation of Aortic Intramural Hematoma: A Case Report and Literature Review

Aortic intramural hematoma (AIH) is a life-threatening emergency that involves aortic wall integrity and is characterized by either a direct rupture of the vasa vasorum or spontaneous bleeding of an arterial plaque located in the tunica media of the aortic wall. A notable difference between AIH and acute aortic dissection is the absence of an intimal flap, a finding discernable on computed tomography angiography (CTA). Follow-up imaging allows for the monitoring of disease progression or early findings of impending complications. While some patients may require surgical intervention, medical management with blood pressure control remains the mainstay in treatment. Our case describes a patient who was found to be in cardiac arrest secondary to ventricular fibrillation and was then found to have presumed Stanford Type A aortic dissection on CTA. After reviewing the scans, the diagnosis was reclassified to AIH due to the absence of an intimal flap, the patient was then managed medically for AIH with antihypertensive medications.

Ascending aortic intramural hematoma: current concepts

PURPOSE OF REVIEW

Type A intramural hematoma (TAIMH) is an acute aortic disease characterized by the presence of hematoma in the aortic media and involving the ascending aorta. Open repair seems to be the first treatment approach, although recent evidence highlights that the best management of TAIMH is controversial. This review will focus on the current concept for TAIMH management and factors affecting the decision making.

RECENT FINDINGS

Recent studies have evaluated the role of open and endovascular repair, as well as conservative management in patients with TAIMH. More specific imaging findings seem to affect decision making for urgent repair.

SUMMARY

Despite TAIMH's acute nature, conservative management seems to represent a valid option for urgent approach, presenting similar mortality to open and endovascular repair. Comparative data are limited, however, in experienced centers, any approach may be applied with encouraging results. Endovascular management, which is mainly applied to manage retrograde TAIMH, is related to lower mortality and morbidity compared to open repair in this group of patients while aortic remodeling seems beneficial with this approach. Imaging findings, as ulcer-like lesions, hematoma thickness, concomitant dissection and aortic diameter, related to higher complication rate, set the indication for interventional management. Further research, including prospective data and registries, and ideally, randomized data may further clarify the best approach and factors indicating urgent repair.

Aortic intramural hematoma and classic aortic dissection: two sides of the same coin within the acute aortic syndrome for an interventional radiologist

Management of acute type B aortic intramural haematoma (AIH) still represents a challenging issue. Although most resolve spontaneously or with conservative therapy, several cases of AIH may complicate into classic aortic dissection with subsequent risk of aortic rupture and visceral malperfusion, thus needing urgent or preemptive thoracic endovascular aneurysm repair (TEVAR). Despite the long-term aorta-related survival, TEVAR might lead to graft obstruction, migration, infection, stroke/paraplegia, visceral ischemia, endoleak and, last but not least, retrograde aortic dissection (AD), frequent in the acute phase and associated with a high mortality risk. In order to highlight such a close relationship between AIH and AD and the possibility to perform endovascular treatment, we report the experience of an adult female patient with an aortic intramural haematoma evolving into a classic aortic dissection. Despite successful thoracic endovascular aneurysm repair (TEVAR), our patient developed an aortic dissection type A at one month with subsequent indication for cardiac surgery still representing the elective approach in case of pathologies including the ascending aorta. Thus, the aim of our discussion is to create a debate on the most appropriate management for the treatment of descending AIH.

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.

MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal

Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient’s management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replicable, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.

Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review

The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.