Long-term behavior of aortic intramural hematomas and penetrating ulcers

Area of Science:

• Cardiovascular Surgery
• Vascular Surgery
• Thoracic Surgery

Background:

• Intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU) are distinct aortic pathologies with debated long-term outcomes and optimal treatment strategies.
• These conditions, often grouped with aortic dissections, require careful evaluation for accurate prognosis and management planning.

Purpose of the Study:

• To evaluate the long-term clinical behavior, radiologic progression, and survival outcomes of patients diagnosed with IMH or PAU.
• To compare the incidence of rupture and the need for late surgical intervention between IMH and PAU.
• To analyze the impact of initial treatment strategies (medical vs. surgical) on survival for both IMH and PAU.

Main Methods:

• A retrospective review of 108 patients with IMH or PAU treated between 1995 and 2014 at Yale-New Haven Hospital.
• Data collection included medical records, radiology imaging, and mortality databases for radiologic follow-up and survival analysis.
• Patient demographics, presenting symptoms (including rupture state), and treatment modalities were analyzed.

Main Results:

• IMH and PAU showed a higher incidence of rupture-state symptoms on admission (18% and 32%, respectively) compared to type A (8%) or B (4%) aortic dissections.
• No cases of branch vascular occlusion were observed in the IMH group.
• Radiologic follow-up revealed worsening in 57% of IMH patients and 30% of PAU patients, often necessitating late surgery. Stable disease was noted in 55% of PAU patients.
• Overall survival rates at 1, 3, 5, and 10 years were 77%, 70%, 58%, and 33%, respectively.
• Patients with PAU initially treated surgically demonstrated significantly better long-term survival than those treated medically (P = .037), a difference not observed in the IMH group (P = .10).

Conclusions:

• IMH and PAU carry a substantial risk of early rupture, exceeding that of typical aortic dissections.
• IMH does not appear to cause branch artery occlusion.
• Patients with IMH and PAU rarely show spontaneous improvement on imaging, frequently requiring delayed surgical intervention.
• Initial surgical management for PAU is associated with improved long-term survival compared to medical management, whereas this distinction was not evident for IMH in this cohort.