Long-term behavior of aortic intramural hematomas and penetrating ulcers.
OBJECTIVE
For intramural hematoma and penetrating atherosclerotic ulcer, long-term behavior and treatment are controversial. This study evaluates the long-term behavior of intramural hematoma and penetrating atherosclerotic ulcer, including radiologic follow-up and survival analysis.


METHODS
Between 1995 and 2014, 108 patients (mean age, 70.8 ± 10 years; 56% female) presented with intramural hematoma or penetrating atherosclerotic ulcer to Yale-New Haven Hospital (New Haven, Conn). We reviewed the medical records, radiology, and online mortality databases.


RESULTS
Ten of 55 patients (18%) with intramural hematoma and 17 of 53 patients (32%) with penetrating atherosclerotic ulcer had rupture state symptoms on admission, both greater than type A (8%) or type B dissection (4%) (P < .001). No branch vascular occlusion occurred. For patients with intramural hematoma with follow-up imaging, 8 of 14 (57%) worsened (mean follow-up, 9.4 months) and 6 (43%) underwent late surgery. For patients with penetrating atherosclerotic ulcer with follow-up imaging, 6 of 20 (30%) worsened and underwent late surgery, and 11 (55%) showed no change (mean follow-up, 34.3 months). Overall survivals were 77%, 70%, 58%, and 33% at 1, 3, 5, and 10 years, respectively. No operative deaths occurred for patients with nonrupture state. Patients with penetrating atherosclerotic ulcer with initial surgical treatment had better long-term survival than patients treated medically (P = .037). In the intramural hematoma group, no such difference was observed (P = .10).


CONCLUSIONS
At presentation, the incidence of early rupture of intramural hematoma and penetrating atherosclerotic ulcer was higher than for typical dissection. For branch vessels, intramural hematoma never occludes branch arteries. On imaging follow-up, patients with intramural hematoma and penetrating atherosclerotic ulcer rarely improved, with late surgery commonly needed. Better survival was observed for the initial surgical management of patients with penetrating atherosclerotic ulcer compared with initial medical management.
Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
Alan S
AS
Chou
Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia.
Bulat A
BA
Ziganshin
Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
Paris
P
Charilaou
Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
Maryann
M
Tranquilli
Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Economics and Department of Preventive Medicine, Stony Brook University, Stony Brook, New York, NY.
John A
JA
Rizzo
Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn. Electronic address: john.elefteriades@yale.edu.
John A
JA
Elefteriades
D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D001018:Aortic Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D001019:Aortic Rupture / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D001027:Aortography / Q000379:methods; D003237:Connecticut; D005260:Female; D006406:Hematoma / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014456:Ulcer / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*
intramural hematoma; long-term follow-up; penetrating atherosclerotic ulcer