Aortic ulcer – intramural hematoma- aortic dissection: a continuous spectrum R Erbel, H Eggebrecht, D Baumgart, J Debatin J Barkhausen,U Herold, H Jakob Department of Cardiology Radiology and Thoracic and Cardiovascular Surgery University Essen, Germany
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Aortic ulcer – intramural hematoma- aortic dissection: a continuous spectrum
R Erbel, H Eggebrecht, D Baumgart, J DebatinJ Barkhausen,U Herold, H Jakob
Department of Cardiology Radiology and Thoracic and Cardiovascular Surgery
University Essen, Germany
Classification of acute aortic syndromes
Svensson LG et al.Circulation 99: 1331-6, 20001- Classic dissection
2- Intramural
hematoma
3- Discrete/subtitle
dissection
4- Plaque ulcer,
plaque rupture
5- Iatrogenic/traumatic
dissection
1 2 3
4 5
ESC TF Eur Heart J 22: 1642 81, 2001
History of IMH• 1920 Krukenberg: Bleeding to the outer layer of the media due to rupture of vasa vasorum without tear.• 1952 Gore,• 1958 Hirst and 1982 Wilson: pathologic studies• 1988 Yamada et al: 1st CT and MRI study• 1991 Zotz et al: 1st IMH FU to AD by TEE• 1994 Mohr-Kahaly: 1st TEE clinical study and FU• 2000 v Kodolitsch et al: „Hemorrhagic stroke of the
aortic wall“
Cystic Media Necrosis
Collagen Fiber Rupture
Cystic Media Necrosis
Collagen Fiber Rupture and Intramural Hemorrhage
Desc. Aorta SAX at 35 cm
Intramural Hematoma Typ I
N = 17
X = 64 years
3 – 20cm length
0.7 – 3 cm W Th
35% echolucent zones
Mohr-Kahaly et al JACC 23:658 – 64, 1994
Intramural
Hematoma Type II
with Vessel Wall
Layering and
Shearing N = 10
-Age 70 years
-Aortic ectasia,aneurysm
-Calcium displacement
-3 – 23 cm length
-0.7 – 4 cm W Th
- 70 % echolucent zones
Mohr-Kahaly et al JACC 23:658 – 64, 1994
- Hematoma formation within the aortic wall in the absence of a
detectable intimal tear (wall thickening)
- Due to spontaneous rupture of vasa vasorum
- Potential precursor of overt dissection class 1
- Class 2 aortic dissection
Intramural hematoma (IMH)
Erbel R, EHJ 2001
Vilacosta, Am Heart J 1997
- Displacement of intimal calcifications
- Affects long segment of the aorta
Intramural hematoma, Class 2 AD (IMH)
Differentiation against thrombosed aneurysm
Meta-Analysis1 (143 patients):
- 5-20% of patients with acute aortic syndromes
- 61% men, mean age 68 yrs.
- 53% hypertension
- Rare: traumatic (motor vehicle accident)
- 80% chest pain
- ~ 21% mortality
Intramural hematoma (IMH)
1Maraj et al,, Am J Cardiol 2000
Outcome1:
IMH- Outcome
1Mara et al,, Am J Cardiol 2000
Intramural Hematoma
Aortography
IVUS
Class 2 AD type B
Intravascular Ultrasound
Pericardial tamponade, progression to dissection, rupture
within one week despite
RR control
IMH- Complications
History of PAU Reports
• 1935 Shennan T 4/218 cases AD begin in the
base of AU
• 1941 Will ius /Cragg „some of AD accociated with
ulcerating atheromatous
abscesses“• 1973 Gore/Hirst < 4% cause of AD• 1986 Stanson: Penetrating aortic ulcer
PAU
Vilacosta et al JACC 32:83 – 9,1998
- Elderly, hypertensive patients
- Symptomatic vs. asymptomatic (incidental finding)
- Most common site: mid/distal descending thoracic aorta
- Strong association with concomitant abdominal aneurysm
Penetrating Atherosclerotic Ulcer (PAU)
Atheroma Plaque erosion
Intimal ulcer PAU+IMH Pseudoaneurysm Rupture
Von Kodolitsch, Z Kardiol 1998
- Ulceration of aortic atherosclerotic plaque penetrating
through the internal elastic lamina into the media
- Class 4 aortic dissection
- 2.3 - 7.6% in symptomatic patients with acute aortic
syndromes
Penetrating Atherosclerotic Ulcer (PAU)
CTIVUSErbel R, EHJ 2001
Plaque Rupture class 4 AD
Ao
Fibrous cap
Ulcer core
1 cm
Erbel R Heart 2001
IVUS
MRI Imaging
PAU- Complications
- Intramural hematoma :• 10 – 100% 1,2
•due to erosion of vasa vasorum• upredictor of adverse outcome
IMH
IMH
(Ganaha et a. Circulation 2002)1. Vilacosta et al JACC 1998
Prognosis of PAU Total Type A Type BAortic dissection 16 % 57 % 12 %Rupture 12 % 57 % 5 %Stable without surgery 54 % 0 % 75 %Mortality surgery 13 % 0 % 13 % med Th 26 % 100 % 11 % total mortality 19 % 57% 14 %
v. Kodolitsch et al Z Kardiol 87:917 – 27,1998
Clinical Features of PAU
• Age > 65 years sex: M 60%• 15 % Type A, Type B 85 %• RF: EH 85 %, Smoking 72 %, HLP 35 %• 85 % Single PAU, 4 % two, > 2 PAUs 11 % • 73 % IMH• 16 % AD, 4 % typical class 1AD• 27 % Pseudoaneurysm• 19 % Fusiforme Aneurysm• 12% Rupture v. Kodolitsch et al Z Kardiol 87:917 – 27,1998
93 References, nearly all case reports
FOLLOW UP IMH
Ascending aorta:n= 3 1surgery 1ruptur 1 dissectionDescending aorta:n=24 4 dissection 3 surgery 3 healing 6 death
Assessment of the true and false lumen Ao desc 23 cm
1.19 cm
Visualisation of Intimal Tearusing 3D-Echocardiography
Non communicating dissection type B 38 cm
Aortic dissection classification
Morphology of False Lumen
WL
FL
WL
FL
WL
FL
Pitfalse
Artefacts
Explanation: Reverberationof the aortic wall, chest wallNot integrated in the anatomy of the aorta
Intramural Hematoma class 2 AD
Transesophageal Echocardiography
Erbel R, Heart 2001
Intramural Hematoma
No Intimal flap! circular or half mond-thickening of Aortic wall >7mmCalcification of intima
Mohr - Kahaly et al JACC 1993
class 2 AD Dissection
Drohende Perforation bei Plaqueruptur in der descendierenden Aorta
thoracalis
Pleuraerguß
Plaque-rupture
Aortensklerose
Klasse 4 AD
Case 2
Angio-Spiral CT mit KM
Aortendissektion Klasse 2
Diagnostik von Aortenerkrankungen
Magnetresonanztomographie
Aortendissektion Aneurysma
Klasse 1
Aortographie
TL
FL
Aortendissektion Klasse 1
Svensson LG et al. Circulation 1999
Begrenzte Aortendissektion Klasse 3
Intravaskulärer Ultraschall (IVUS)
Plaqueruptur(Klasse 4)
Plaquerupturder Aorta Abdominalis(Klasse 4)
IntramuralesHämatom(Klasse 2)
Eggebrecht H, et al., Heart 2001
Angio-Spiral CT
Case 2
• Physical examination: percussion sound dullness over left lower chest and 2/6 systolic murmur heard best over the 2nd intercostal space at the right parasternal line
• Signs of emergency: periaortic -, mediastinal hematoma,
pleural, pericardial effusionOP / Stent - Graft-Stent / medical therapyOP / Stent - Graft-Stent / medical therapy
II IIII
IMH- Therapeutic approach
- Ascending aorta - Descending aorta
Surgery
Type-A IMH Type-B IMH
No risk factors
Medical Tx
Risk factors:• Recurrent pain• Progression to dissection• Pleural effusion
Stent-Graft (?)
Definition of IMH• Wall thickening < 7 (5) mm• Segmental/crescentic wall thickening• Thrombus – like appearance• Wall layering,layer shifting• Absence of tear(s) and flow • Echolucent zones (+/-),high signal intensity• Central calcium displacement
Mohr-Kahaly et al JACC 23:658 – 64, 1994
Mohr-Kahly JACC 37:1611- 13, 2001
TYPE I INTRAMURAL HEMATOMA• smooth luminal surface• circular thickening of the wall• aortic diameter normal (3.5 cm)