INTRAMURAL HEMATOMA OF THE THORACIC AORTA

Objective: This study was designed to clarify the optimal treatment mo de of patients with intramural hematoma (IMH) of the thoracic aorta. M ethods: 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 pati ents (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 pa tients 13 required aortic arch repairs and the remaining 5 underwent c onservative therapy including anti-hypertensive medication. Primary in dications 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 i n 2 of which 1 had a coexisting aortic arch aneurysm. The 2-year survi val rate after diagnosis was 94% with an operation-free rate of 25%. N ine of the group II patients experienced surgical intervention of whic h 8 had intimal disruption. 4 patients received urgent replacement of the descending thoracic aorta for massive pleural effusion and 1 had t he aortic arch replaced for a coexisting aneurysm with persistent pain . All other patients underwent conservative treatment and 4 of them ha d to be shifted to early surgery during the initial hospitalization be cause of an enlarged ulcer. The 5 year survival rate in group II patie nts was 63% with an operation-free survival rate of 66%. Conclusions: On the basis of our experience early operation is recommended for almo st all patients with ascending aortic IMH, and medical therapy for tho se with descending aortic involvement unless complication developed. H owever, the presence of intimal disruption map require early surgical treatment even in the patients with descending thoracic IMH. (C) 1998 Elsevier Science B.V. All rights reserved.