Long-term behavior of aortic intramural hematomas and penetrating ulcers

J Thorac Cardiovasc Surg. 2016 Feb;151(2):361-72, 373.e1. doi: 10.1016/j.jtcvs.2015.09.012. Epub 2015 Sep 16.

Abstract

Objective: For intramural hematoma and penetrating atherosclerotic ulcer, long-term behavior and treatment are controversial. This study evaluates the long-term behavior of intramural hematoma and penetrating atherosclerotic ulcer, including radiologic follow-up and survival analysis.

Methods: Between 1995 and 2014, 108 patients (mean age, 70.8 ± 10 years; 56% female) presented with intramural hematoma or penetrating atherosclerotic ulcer to Yale-New Haven Hospital (New Haven, Conn). We reviewed the medical records, radiology, and online mortality databases.

Results: Ten of 55 patients (18%) with intramural hematoma and 17 of 53 patients (32%) with penetrating atherosclerotic ulcer had rupture state symptoms on admission, both greater than type A (8%) or type B dissection (4%) (P < .001). No branch vascular occlusion occurred. For patients with intramural hematoma with follow-up imaging, 8 of 14 (57%) worsened (mean follow-up, 9.4 months) and 6 (43%) underwent late surgery. For patients with penetrating atherosclerotic ulcer with follow-up imaging, 6 of 20 (30%) worsened and underwent late surgery, and 11 (55%) showed no change (mean follow-up, 34.3 months). Overall survivals were 77%, 70%, 58%, and 33% at 1, 3, 5, and 10 years, respectively. No operative deaths occurred for patients with nonrupture state. Patients with penetrating atherosclerotic ulcer with initial surgical treatment had better long-term survival than patients treated medically (P = .037). In the intramural hematoma group, no such difference was observed (P = .10).

Conclusions: At presentation, the incidence of early rupture of intramural hematoma and penetrating atherosclerotic ulcer was higher than for typical dissection. For branch vessels, intramural hematoma never occludes branch arteries. On imaging follow-up, patients with intramural hematoma and penetrating atherosclerotic ulcer rarely improved, with late surgery commonly needed. Better survival was observed for the initial surgical management of patients with penetrating atherosclerotic ulcer compared with initial medical management.

Keywords: intramural hematoma; long-term follow-up; penetrating atherosclerotic ulcer.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Aneurysm / diagnosis
  • Aortic Aneurysm / mortality
  • Aortic Aneurysm / surgery
  • Aortic Aneurysm / therapy*
  • Aortic Diseases / diagnosis
  • Aortic Diseases / mortality
  • Aortic Diseases / surgery
  • Aortic Diseases / therapy*
  • Aortic Dissection / diagnosis
  • Aortic Dissection / mortality
  • Aortic Dissection / surgery
  • Aortic Dissection / therapy*
  • Aortic Rupture / diagnosis
  • Aortic Rupture / mortality
  • Aortic Rupture / surgery
  • Aortic Rupture / therapy*
  • Aortography / methods
  • Connecticut
  • Female
  • Hematoma / diagnosis
  • Hematoma / mortality
  • Hematoma / surgery
  • Hematoma / therapy*
  • Humans
  • Kaplan-Meier Estimate
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Factors
  • Time Factors
  • Tomography, X-Ray Computed
  • Treatment Outcome
  • Ulcer / diagnosis
  • Ulcer / mortality
  • Ulcer / surgery
  • Ulcer / therapy*