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DOI: 10.1055/s-0032-1332661
Intramural hematoma or aortic dissection?
Introduction: The treatment of intramural hematoma remains challenging and was discussed controversially between cardiologists, surgeons and radiologists. At our department we tend to treat intramural hematoma comparable to type A dissections and promote aggressive early surgical treatment.
Aims: An 83-year-old female presented to her local hospital with acute chest pain. Computer tomography scan (CT-scan) revealed a type A aortic dissection or intramural hematoma with a circular thrombosed lumen. The thrombosed lumen extended from the ascending aorta to the descending aorta including the aortic arch and the brachiocephalic artery. The maximum diameter of the ascending aorta was 48 mm without any pericardial effusion. On physical examination at our institution her pulse rate was 80 bpm and blood pressure was 110/75 mmHg, equal in both arms. Transesophageal echocardiography (TEE) demonstrated good ventricular function (LVEF 65%), mild aortic valve regurgitation. Moreover, the TEE showed a maximum diameter of the ascending aorta comparable to the measurements of the CT-scan. There was a thrombosed lumen with a maximum of 2 – 3 mm, without classical intimal flap or patent false lumen. In the operating room early after hospitalization, we found an aneurysm of the ascending aorta with a reddish and bluish discoloration. The ascending aorta was transected and representative part of the aorta was removed. Here we were able to show an extensive thrombosed aortic dissection lumen with evidence of a ruptured intimal plaque. After complete debridement of the hematoma, the ascending aorta was replaced with a 28-mm Vascutek prostheses from the sinotubular junction to the distal arch. The patient recovered well and was discharged 6 days later.
Discussion: The primary purpose of this report was to show that extended intramural hematoma should be treat like a type A dissection even if there is no classic intimal flaps, patent false lumens, pericardial effusions, aortic valvular regurgitation or malperfusion.