DIAGNOSIS AND TREATMENT OF THORACIC AORTIC INTRAMURAL HEMATOMA

Purpose: This report reviews our recent experience with nine patients who had intramural hematoma of the thoracic aorta. Methods: This was a retrospective study of all patients who had intramural hematoma at ou r institution from 1989 to 1994. Patients who had identifiable intimal flap, tear, or penetrating aortic ulcer mere excluded from the study. Results: Among these nine elderly patients (mean age, 76 years), the most common presentation was chest or back pain. Intramural hematoma w as diagnosed by a variety of high-resolution imaging techniques. The d escending thoracic aorta alone was involved in seven patients, whereas the ascending aorta was affected in the other two patients. One patie nt had evidence of an aneurysm (5.0 cm diameter) in the region of the hematoma. All patients were initially managed nonsurgically with blood pressure control. Both patients who had ascending aortic involvement had progression of aortic hematoma, which resulted in death in one cas e and in successful surgery in the ether. Sis of the seven patients wh o had descending aortic involvement alone were successfully managed wi thout aortic surgery. The patient who had intramural hematoma and asso ciated aortic aneurysm, however, had severe, recurrent pain and underw ent successful aortic replacement. Another patient had recurrent pain associated with hypertension, but was successfully managed nonsurgical ly with antihypertensive therapy. All eight survivors are doing well a t a median follow-up of 19 months. Conclusions: Intramural hematoma ap pears to be a distinct entity, although overlap with aortic dissection or penetrating aortic ulcer exists. Aggressive control of blood press ure with intensive care unit monitoring has been our initial managemen t. Patients who have involvement of the descending thoracic aorta alon e can frequently be managed without surgery in the absence of coexisti ng aneurysmal dilatation or disease progression Our experience suggest s that a more aggressive approach with early surgery is warranted in p atients who ha ie ascending aortic involvement or those who have coexi sting aneurysm and intramural hematoma.