Early aggressive medical treatment associated with selective prophylactic aortic stent-grafting for aortic intramural hematoma.

BACKGROUND: Although recent studies suggest that medical treatment is appropriate for patients with aortic intramural hematoma (IMH), the outcomes of supportive medical treatment alone have not been satisfactory, and clear guidelines for medical treatment are not yet available. We assessed whether a management protocol of combined early aggressive medical treatment and selective prophylactic aortic stent-grafting would benefit patients with IMH.

METHODS: Nineteen patients with IMH were prospectively studied; after initial clinical and radiological evaluation, 13 underwent early aggressive medical therapy (group 1), and 6 underwent early aggressive medical therapy and prophylactic endovascular stent-grafting (group 2).

RESULTS: In group 1, one patient with type A IMH died prior to surgical consultation because of cardiac tamponade; another patient with type A IMH underwent replacement of the ascending aorta at the 6-month follow-up. The condition of the other 11 patients stabilized during hospitalization and after discharge. The disease spontaneously regressed in 10 patients, and the intramural hematoma completely resolved in 5 patients. In group 2, follow-up imaging revealed complete coverage of the penetrating aortic ulcers and regression of the intramural hematoma; endovascular leaks have not yet occurred.

CONCLUSIONS: Our protocol may be used as an alternative approach for patients with IMH. After initial clinical and radiological evaluation, the condition of patients without complications can be stabilized with medical treatment; frequent follow-up imaging is required in such cases. Early aggressive medical treatment combined with prophylactic aortic stent-grafting is a safe and effective treatment modality for IMH patients with penetrating aortic ulcers in the descending aorta.