Abstract

Objective: Confusion exists regarding the treatment of intramural hematomas of the aorta.

Material: Since 1994 20 patients were evaluated either by magnetic resonance imaging or computed tomography (CT) (in addition to transesophageal echocardiography) to have a hematoma in the aortic wall. Follow up is 6--48 months.

Results: Ascending aorta: Initial symptoms in 8/10 patients were acute pains. Three patients had hematoma in the ascending aorta together with a dissection in the descending aorta; 2/3 had uneventful recoveries with conservative treatment. Five patients were operated as emergencies (mortality 1/5), two of whom underwent surgery after one week when a double lumen had developed. A rupture of the intima was found in every case. One patient died immediately after CT investigation, and autopsy showed intimal rupture. A 'hematoma-like' thickening of the wall was found accidentally in two patients; both were successfully treated conservatively.

Descending aorta: All 10 patients started acutely. 9/10 patients had an intramural hematoma. Follow up after conservative treatment showed almost complete normalisation of the aortic wall. One patient was primarily diagnosed as a ruptured aneurysm of the descending aorta. Surgery (and autopsy) showed an intramural hematoma with rupture to the pleura without any intimal lesion.

Conclusions: Intramural hematomas of the ascending aorta are true dissections, whereas hematomas in the descending aorta may be bleeding from vasa vasorum, and not necessarily communicate with the lumen of the aorta. Treatment should be aggressive surgery for acute lesions of the ascending aorta and conservative for lesions in the descending aorta.