Management of aortic intramural hematoma not associated with penetrating aortic ulcer

CT: computed tomography; IMH: intramural hematoma; MR: magnetic resonance.

* For any IMH (type A or type B), high-risk features include progression to aortic dissection, increasing aortic diameter, and increasing hematoma thickness^[1].

• Specific high-risk features for type A IMH include maximum aortic diameter >45 to 50 mm, hematoma thickness ≥10 mm, focal intimal disruption with ulcer-like projection involving the ascending aorta or arch, and pericardial effusion on admission.
• Specific high-risk features for type B IMH include maximum aortic diameter >47 to 50 mm, hematoma thickness ≥13 mm, focal intimal disruption with ulcer-like projection involving the descending thoracic aorta if it develops in acute phase, and increasing or recurrent pleural effusion.

¶ Anti-impulse therapy aims to reduce aortic shear stress and minimize lesion progression by reducing blood pressure and heart rate, typically initially using intravenous beta blockers.

Δ For patients who require repair of a IMH in the ascending aorta or proximal aortic arch (zones 0-1), open surgical repair is recommended. For patients who require repair of a IMH in the distal aortic arch (zones 2-3), descending thoracic aorta (zones 4,5), or abdominal aorta (zones 6,7,8,9), either open surgical repair or endovascular repair is reasonable, based on anatomy and medical comorbidities.

◊ Baseline imaging (CT/MR angiography) is obtained prior to discharge, with follow-up examinations at 3, 6, and 12 months, and annually thereafter.