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Interact CardioVasc Thorac Surg 2007;6:255-256. doi:10.1510/icvts.2006.149187 © 2007 European Association of Cardio-Thoracic Surgery
Recurrent type B intramural hematoma progressed into type A acute aortic dissection in a young otherwise healthy woman: are there unknown background factors?Department of Thoracic and Cardiovascular Surgery, Inha University Hospital 7-206, 3-Ga, Shinheung-Dong, Jung-Ku Incheon 400-103, South Korea Received 6 December 2006; received in revised form 9 January 2007; accepted 15 January 2007
*Corresponding author. Tel.: +82-32-890-2127; Fax: +82-32-890-3099.
Intramural hematoma is reported with increasing frequency but the recurrence after complete resolution is rarely reported. We herewith describe a case of type B intramural hematoma in an otherwise healthy 39-year-old woman showing unusual clinical course in which acute aortic dissection developed three months after complete resolution of intramural hematoma. The case clearly reminded us of the potential of intramural hematoma for recurrence and progression to frank aortic dissection even after complete resolution.
Key Words: Intramural hematoma; Aortic dissection; Recurrence
Intramural hematoma (IMH) is rather a newly defined disease entity and the optimal management is still controversial as the disease shows varied clinical courses [1]. Some regress spontaneously with medical management alone, while others progress to frank dissection necessitating prompt surgical intervention. Early surgery is advocated in favor of the blockade of disease progression to a much unfavorable communicating aortic dissection, especially in the case of ascending IMH [2, 3]. Here we report a case of acute aortic dissection developing three months after complete resolution of type B IMH and the implication of the case is discussed. A 39-year-old female presented with acute chest pain. She had been healthy, with no history of hypertension or diabetes. A computed tomographic scan revealed an IMH involving proximal part of the descending thoracic aorta (Fig. 1a). The ascending aorta was intact and no penetrating atheromatous ulcers were seen well throughout the whole aorta. She had no clinical features of Marfan disease and serologic markers were negative. Medical treatment was proposed, including strict blood pressure control. On repeated computed tomographic scans during the admission, marked decrease of the extent of IMH was noted with symptomatic improvement. On the 8th hospital day, she was discharged home and managed on an outpatient basis with antihypertensive medications. On the follow-up computed tomographic scan at five weeks after the initial episode, IMH was completely resolved and whole aorta looked entirely normal (Fig. 1b). Nonetheless, her antihypertensive medication was continued and the blood pressure was strictly controlled. Three months later, the patient returned to the emergency department with recurrent chest pain. The computed tomographic scan revealed a frank aortic dissection, involving the ascending aorta, aortic arch and proximal descending aorta (Fig. 1c). Emergency operation was undertaken under the support of routine cardiopulmonary bypass and moderate hypothermia. The tube graft anastomosed to the right axillary artery was used for arterial line. Although intimal tear was suspected in the descending thoracic aorta at the level of pulmonary hilum by computed tomography and the anterior dissection was supposed to be a retrograde one, we preferred the anterior approach via median sternotomy in favor of the manipulation of the ascending aorta, of which the risk of rupture was the greatest. After opening the ascending aorta, the inner aspect of the aorta, including aortic arch, was examined with the aid of a short period of circulatory arrest only to find no intimal tear from the aortic root down to the aortic isthmus, confirming our initial assumption of retrograde aortic dissection with entry point somewhere distal to the aortic isthmus. Only ascending aorta was replaced with the fabric graft in a usual fashion as we thought it was meaningless to extend the operation to the arch in such a circumstance as the entry of dissection to be well beyond aortic arch and unable to be eliminated by arch replacement. The patient recovered well and discharged on 10th postoperative day. Pathology revealed no specific findings other than cystic medial necrosis. Though false lumen is still visible on descending thoracic aorta on follow-up computed tomographic scan, she is doing well without symptoms at six-month follow-up.
IMH behaves in different ways: some regress spontaneously, while others bring about unfavorable outcomes such as frank aortic dissection and/or aortic rupture. The key point of the treatment is to differentiate a group of patients who would be benefited by surgery before a catastrophic event coming in reality, which is not fully established [1]. General agreement was made in favor of surgical treatment in cases involving ascending aorta, as seen in the treatment guidelines of acute aortic dissection [2, 3]. As for etiology, IMH caused by rupture of the vasa vasorum is supposed to behave more malignantly than by penetrating atherosclerotic ulcer [4]. In this case, we could not directly document recurrence of the IMH as an initiating event of her dissection as it developed so rapidly. However, it would be prudent to attribute her dissection to the recurrence of IMH taking account of her recent history of IMH in the coinciding extent of presumed entry site of the aortic dissection. What we learned from this case is that IMH has a potential to recur, which should be differentiated from late progression of the disease. One should bear in mind that careful follow-up is mandatory for IMH even after complete resolution of hematoma being documented. As for operation, frozen elephant technique [5] might be a plausible option for this patient in favor of the elimination of distal intimal disruption. The stent graft, however, was not available at that moment. The aortic intima was exceptionally clean with no evidence of penetrating atheromatous plaque or ulcer in this patient. Any background factor for repeated IMH could not be sought, which should be investigated further.
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Abstract
1. Introduction
