Large Intramural Aortic Hematoma with Intimal Tear

Abstract

A 72-year-old man presented with excruciating epigastric pain. A chest computed tomography angiography revealed an aortic intramural hematoma. A filling defect within the distal ascending aorta was noted. Images of an intramular hematoma and surgical details of an ascending aortic replacement under deep hypothermic circulatory arrest are provided.

Keywords

aortic intramural hematoma - dissection - acute aortic syndrome

A 72-year-old man presented with excruciating epigastric pain not associated with exercise or trauma. After excluding myocardial ischemia, a chest computed tomography angiography revealed an aortic intramural hematoma (IMH) of 5 mm in thickness starting at the sinotubular junction (34 mm) and extending circumferentially to the diaphragm (27 mm; [Fig. 1A–C]). A filling defect within the distal ascending aorta was present ([Fig. 1A–C]).

Fig. 1 (A–C) Chest computed tomography angiography revealing an aortic intramural hematoma in intraluminal filling defect. (D) Intraoperative thrombus covering a small intimal tea.

An ascending aortic replacement was performed under deep hypothermic circulatory arrest. A thrombus covering a small intimal tear was found within the aortic lumen at the distal ascending aorta corresponding to the filling defect ([Fig. 1D]). No other intimal tear was found. The hematoma was removed ([Fig. 1D]) to ensure secure proximal and distal anastomoses, no embolization occurred. The patient was discharged on postoperative day 6 without complication.

Disruption of a vasa vasorum within the media or bleeding within the vicinity of a penetrating atherosclerotic ulcer are the mechanisms reported to cause IMH.[1] [2] Minimal intimal tear with secondary thrombus formation is the probable etiology of IMH in this case. Surgeons performing open and endovascular surgical repair should be aware of this finding and its risks for thromboembolic complications.

Conflict of Interest

The authors declare no conflict of interest related to this article.

Acknowledgments

None.

Editor’s Comments

Surgeons who operate on intramural hematoma (IMH) cases have long noted that intimal tears are often found at surgery, despite their not being seen on radiographic imaging. This is important because it contradicts the conventional wisdom that IMHs represent rupture of vasa vasorum without connection to the lumenal blood flow. The case reported and illustrated by Jacques and colleagues supports an alternate understanding of etiology and pathophysiology of IMH. That is to say, although IMHs do not demonstrate the intimal flap of typical aortic dissection, they may indeed originate via a tear in the intima of the aorta. (Another possibility is that the IMH originates via rupture of a vasa vasorum and subsequently ruptures through the aortic intimal.)

• References

• 1 Alomari IB, Hamirani YS, Madera G, Tabe C, Akhtar N, Raizada V. Aortic intramural hematoma and its complications. Circulation 2014; 129 (06) 711-716
• 2 Sundt TM. Intramural hematoma and penetrating atherosclerotic ulcer of the aorta. Ann Thorac Surg 2007; 83 (02) S835 –S841, discussion S846–S850

Publication History

Received: 15 November 2018

Accepted: 24 May 2020

Article published online:
09 November 2020