Intramural hematoma and penetrating aortic ulcer

Abstract

Purpose of review: With advances in imaging technology, increased attention has turned to the 'variant forms' of aortic dissection: intramural hematoma and penetrating aortic ulcer. At the same time, the advent of endovascular therapies such as stent-grafting has broadened the base of practitioners capable of intervening in these pathologies from the cardiovascular surgeon to now include vascular surgeons, interventional radiologists, and invasive cardiologists. Accordingly, a reassessment of these conditions is of general interest.

Recent findings: The natural history of both entities is being elucidated with increasing precision as relatively large single-center and multicenter studies are being reported. Recent attention has focused on application of endovascular technologies to penetrating aortic ulcer, while the principal controversy over intramural hematoma concerns its management when the ascending aorta is involved.

Summary: Despite continuing controversy over the outcome of penetrating aortic ulcer managed by medical or open surgical means, thoracic endograft technology is being applied to this entity with high procedural success and low perioperative morbidity by experienced teams internationally. The benefit to patients as the use of this technology expands, however, will depend critically upon selection criteria. Evidence in favor of surgical management of type A intramural hematoma continues to mount, although it is also clear that, in specific circumstances, a nonoperative approach may suffice.