Intramural Hematomas of the Thoracic Aorta: Current Management and Outcomes: A Single Institution’s Experience During a Decade

Intramural hematomas (IMHs) of the aorta are a rare variant of aortic dissection without the presence of an intimal flap or defect. Controversy exists as to the optimal management for patients with type A IMH. Our objective was to evaluate the outcomes of surgically and medically managed patients. A retrospective review was performed for patients with a radiologic diagnosis (computed tomography or magnetic resonance angiography) of thoracic IMH at our institution between June 2006 and July 2017. IMH was defined as a circular or crescent-shaped thickening without evidence of a free flap or intimal defect. Thirty-two patients were identified with IMH of the thoracic aorta; 14 involved the ascending aorta (type A), and 18 were isolated to the descending aorta (type B). No differences in age, sex, and medical history were observed between the type A and type B cohorts, with the exception of chronic renal insufficiency being more common in type B patients (P = .024). Four type A IMHs underwent emergent surgical repair; three underwent delayed repair (median, 19 days [5-25 days]). Extravascular blood in the form of periaortic hematoma, hemopericardium, or hemothorax was more frequent in type A (P = .043) than in type B IMH. No difference in survival or time to last clinical follow-up was observed between those who underwent surgery and those who did not (53.2 vs 61.1 months; P = .799). Among the type B IMH group, all 18 were initially managed expectantly, with 6 undergoing eventual surgical or endovascular intervention. No emergent repairs of a type B IMH were performed. No difference in survival or time to last clinical follow-up was observed between those who underwent surgery and those who did not (31.9 vs 39.0 months; P = .759). Unlike type A dissection, type A IMH may be safely treated with medical management in selected patients similar to type B IMH without the need for mandatory emergent surgical intervention.