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文章论述主动脉夹层(AD)、主动脉壁间血肿(出血)、主动脉穿透性溃疡的影像学诊断的进展,并讨论三者的关系,提出影像学检查在诊断和鉴别诊断中具有重要的作用。     

A case report of type I acute aortic intramural hematoma with localized dissection as a complication of renal artery stenting.

Percutaneous renal artery stenting has been demonstrated as an effective procedure to improve blood pressure control and preserve renal function of patients with artherosclerotic renal artery stenosis. Although it is a relatively safe procedure, some serious complications, including retroperitoneal hemorrhage, atheroembolism, and arterial dissection, can occur. However, development of aortic intramural hematoma (AIH), a different clinical disease entity from the aortic dissection, has not been reported as a complication of the procedure. We report a unique case with AIH that was successfully treated with medication. A 71-year-old woman with uncontrolled hypertension underwent percutaneous renal artery stenting for treatment of the ostial stenosis of the right renal artery. Immediately after implantation of the stent, she complained of severe back pain and her systolic blood pressure dropped from 170 to 80 mm Hg. Aortography showed about 5 cm-sized localized dissection arising from the ostium of the right renal artery; however, computerized tomography (CT) scans taken immediately after the procedure revealed DeBakey type I AIH with a localized dissection from the right renal artery and pericardial effusion. Because of her refusal to take surgical intervention, which is a standard treatment, she was stabilized with intensive medical treatment. After 14 days of stabilization, AIH and pericardial effusion resolved on the follow-up CT scans. Her blood pressure was well controlled with oral antihypertensive medications and she was discharged without other complication.     

Different clinical features of aortic intramural hematoma versus dissection involving the descending thoracic aorta

OBJECTIVE: The objective of this study is to test the hypothesis that the absence of flow communication in aortic intramural hematoma (IMH) involving the descending aorta may have a different clinical course compared with aortic dissection (AD). METHODS: We prospectively evaluated clinical and echocardiographic data in AD (76 patients) and IMH (27 patients) of the descending thoracic aorta. RESULTS: Patients did not differ with regard to age, gender, or clinical presentation. IMH and AD had the same predictors of complications at follow-up: aortic diameter (>5 cm) at diagnosis and persistent back pain. Surgical treatment was more frequently selected in AD (39% vs. 22%, P < 0.01) and AD patients who underwent surgical treatment had higher mortality than those with IMH (36% vs. 17%, P < 0.01). There was no difference in mortality with medical treatment (14% in AD vs. 19% in IMH, P = 0.7). During follow-up, of 23 patients with IMH, 11 (47%) showed complete resolution or regression, 6 (26%) increased the diameter of the descending aorta, and typical AD developed in 3 patients (13%). No changes occurred in 14% of the group. Three-year survival rate did not show significant differences between both groups (82 +/- 6% in IMH vs. 75 +/- 7% in AD, P = 0.37). CONCLUSION: IMH of the descending thoracic aorta has a relatively frequent rate of complications at follow-up, including dissection and aneurysm formation. Medical treatment with very frequent imaging and timed elective surgery in cases with complications allows a better patient management.     

B型主动脉壁间血肿治疗策略的选择

目的:探讨Standford B型主动脉壁间血肿的治疗策略的选择。方法: 总结我院2年期间通过内科药物和腔内修复手术治疗的Standford B型主动脉壁间血肿患者16例,根据患者治疗结果进行评价主动脉壁间血肿治疗策略的选择。结果: 16例患者中,药物治疗的患者6例,腔内修复治疗的患者10例（其中4例是由于药物治疗后症状持续加重转为腔内修复手术治疗的）。腔内治疗患者均存活,药物治疗组中死亡2例,均为出现急性主动脉夹层引起死亡。结论: 腔内修复治疗对于Standford B主动脉壁间血肿是安全可行治疗选择。     

Definitive diagnosis of descending thoracic aortic dissection by real time/live three-dimensional transthoracic echocardiography

We describe a patient with descending thoracic aortic dissection in whom three- dimensional transthoracic echocardiography was able to clearly visualize the dissection flap en face as a sheet of tissue, as well as demonstrate a large communication between the true and false lumen in three dimensions, enabling a definitive diagnosis of dissection.     

Intramural hematoma of the aorta caused by a penetrating atheromatous ulcer

Aortic dissection is a life-threatening condition which is difficult to diagnose because of its variable clinical presentation and diverse pathophysiologic manifestations. We present a case in which intramural hematoma of the thoracic aorta occurred in the absence of an intimal flap. Computed tomography and magnetic resonance imaging both showed hemorrhage in the wall of the aorta. Transesophageal echocar-diography also revealed a penetrating atherosclerotic ulcer in the transverse aorta as a cause of the hematoma. A high index of clinical suspicion and a combination of diagnostic procedures resulted in proper diagnosis and successful surgical treatment.     

主动脉壁间血肿误诊为急性腹痛1例报告

在急性主动脉综合征中,主动脉壁间血肿（IMH）是潜在致命的急症之一。它的主要危险并发症是进展为主动脉夹层,导致主动脉破裂、形成主动脉瘤或者完全吸收,早期诊断和治疗至关重要。但是,并不是所有IMH患者都具有典型的临床表现,早期诊断困难,容易引起误诊。IMH仅以急性腹痛起病实属罕见,笔者报道了1例以急性腹痛起病的68岁老年男性患者,最初误诊为其他腹部疾病,后经影像学检查得以确诊。急诊医师对仅表现为急腹症的IMH肿应引起注意,以做到早期诊断和处理。     

Rapid diagnosis and management of thoracic aortic dissection and intramural haematoma: a prospective study of advantages of multiplane vs. biplane transoesophageal echocardiography.

AIMS: The purposes of this study were to compare the accuracy of multiplane vs. biplane transoesophageal echocardiography (TEE) in the diagnosis of aortic dissection and aortic intramural haematoma, and to test whether these techniques provide all the diagnostic information required to make management decisions. METHODS AND RESULTS: Fifty-eight consecutive patients with clinically suspected aortic dissection were studied with multiplane TEE; all cases who required surgery underwent intraoperative monitoring with multiplane TEE. The following multiplane TEE data were analysed: the angle between current and 0 degrees plane at which each view was obtained; the success rate in the evaluation of true and false lumen, entry tear, coronary artery involvement, aortic regurgitation, pericardial effusion. Advantages of multiplane over biplane TEE have been evaluated by the demonstration of usefulness of views obtained in planes other than 0 degrees-20 degrees or 70 degrees-110 degrees, assuming that with manipulation of a biplane probe a 20 degrees arc could be added to the conventional horizontal and vertical planes. On the basis of TEE findings, aortic dissection was confirmed in 36 cases (18 type A, 12 type B, six intramural haematoma). The specificity and sensitivity of TEE in terms of the presence or absence of aortic dissection or intramural haematoma were 100%. An additional clinical value of multiplane over biplane TEE in the evaluation of ascending aorta, aortic arch, entry tears and coronary artery involvement was demonstrated. All cases with type A aortic dissection or intramural haematoma involving the ascending aorta had an operation that was performed immediately after the diagnosis (hospital mortality, 13%). Patients with type B aortic dissection were treated medically; 25% of these cases were operated later (hospital mortality, 0%). CONCLUSIONS: Multiplane and biplane TEE have excellent and similar accuracies in the evaluation of aortic dissection and intramural haematoma. Multiplane TEE improves the visualization of coronary arteries, aortic arch and entry tears; it appears to be an ideal method as the sole diagnostic approach before surgery in type A aortic dissection.     

Complication of hybrid treatment in type B aortic dissection diagnosed by echocardiography

This case illustrates an unusual and fatal complication after endovascular treatment of type B aortic dissection and highlights the role of echocardiography in the early diagnosis of complications. In this case, a patient with previous diagnosis of chronic type B aortic dissection and moderate aortic regurgitation underwent endovascular repair of the proximal descending aorta and conservative surgical correction of the aortic valve. On early postoperative, a transesophageal echocardiogram and aortic angiotomography demonstrated proximal endoleak by contrast extravasation around the proximal graft attachment site, causing compression of the stent in its middle portion, resulting in narrowing with reduced cross‐sectional area.     

Missed diagnosis of limited ascending aortic dissection by multiple imaging modalities leading to fatal cardiac tamponade and aortic rupture

Modern diagnostic imaging modalities for ascending aortic dissection include transesophageal echocardiography (TEE), computed tomography angiography (CTA), and magnetic imaging resonance (MRI). All have extremely high sensitivity and specificity for detection of an intimal flap to diagnose ascending aortic dissection. We present a case of fatal cardiac tamponade caused by a limited aortic dissection not detected by multiple imaging modalities. This may represent a class of aortic dissection variant that cannot be detected by conventional testing. A high index of suspicion should be maintained in the appropriate clinical setting and should prompt serial imaging and even consideration for preemptive surgical exploration.     

Diagnostic potential of combined transthoracic echocardiography and x-ray computed tomography in suspected aortic dissection.

BACKGROUND: Transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are considered optimal diagnostic methods in the setting of suspected aortic dissection. However, although less sensitive as single modalities, transthoracic echocardiography (TTE) and contrast-enhanced computed tomography (x-ray CT) are more widely available and less costly. HYPOTHESIS: This study was undertaken to compare the diagnostic performance and reliability of the combined use of TTE and x-ray CT with TEE and/or MRI findings in the setting of suspected aortic dissection. METHODS: The diagnostic power of combined TTE and x-ray CT was compared with both single use of TTE and x-ray CT and with TEE and/or MRI in a series of 168 consecutive patients with suspected aortic dissection (AD). Of these, 28 women and 58 men (mean age 53 +/- 16 years) underwent TTE and x-ray CT prior to TEE (n = 52) and/or MRI (n = 69). Diagnostic results of combined TTE/x-ray CT were retrospectively but independently reevaluated in blinded fashion; diagnostic findings were validated by angiography (n = 63), surgery (n = 52), or autopsy (n = 7). RESULTS: Type A dissection was found in 29 patients (34%), type B dissection in 10 (12%), whereas aortic dissection was excluded in 47 (55%). With 95%, the sensitivity of TTE and x-ray CT was significantly enhanced when used in a combined access compared with 67 and 79%, respectively, when used as single methods (95%; p < 0.05). Sensitivity and specificity (95 and 91%, respectively) of combined TTE/x-ray CT evaluation were not different from TEE and/or MRI (100 and 96%, respectively; NS). Thrombus formation, side-branch involvement, aortic regurgitation, pericardial effusion or mediastinal hematoma were also detected with similar sensitivities and specificities both by combined TTE/x-ray CT and TEE and/or MRI. CONCLUSION: This first controlled study comparing the combined information of TTE and x-ray CT with TEE and/or MRI revealed a similar diagnostic potential of both diagnostic strategies in the setting of suspected aortic dissection. Thus, in an environment with access to color Doppler TTE and x-ray CT only, the information from both tests should be combined to decide on diagnostic management of these patients.     

Multimodality imaging of aortic dimensions: comparison of transthoracic echocardiography with multidetector row computed tomography

Background: With recent advances in multimodality cardiac imaging, a number of methods exist for the noninvasive assessment of aortic disease. Although multidetector row computed tomography (MDCT) remains the gold standard for aortic measurements, there are a number of limitations including radiation and contrast‐induced nephropathy. Transthoracic echocardiography (TTE) is an alternative to MDCT for providing accurate anatomic assessment of aortic root and ascending aorta dimensions. Objectives and Methods: To determine the accuracy of two‐dimensional (2D) TTE for determining aortic measurements in comparison to MDCT, a retrospective study of individuals with varying aortic root and ascending aorta dimensions was performed. Results: There were 116 patients (77 males, mean age 49 ± 12 years) in total. The maximum aortic diameters by 2D TTE were 26.1 ± 4.3 mm (annulus), 32.4 ± 5.6 mm (sinuses), 30.1 ± 5.9 mm (sinotubular [ST] junction), and 33.4 ± 7.3 mm (ascending aorta). The maximum aortic diameters by MDCT were 30.1 ± 4.1 mm (annulus), 35.8 ± 5.8 mm (sinuses), 33.2 ± 5.9 mm (ST junction), and 37.4 ± 7.6 mm (ascending aorta). There was good to excellent correlation between 2D TTE and MDCT at all four levels of the aorta (annulus: r = 0.84; sinuses: r = 0.93; ST junction: r = 0.93; ascending aorta: r = 0.88). There was a consistent underestimation of aortic measurements obtained by 2D TTE when compared to MDCT. Conclusion: 2DTTE is a feasible, accurate, and reproducible method for the noninvasive assessment of thoracic aortic diameters as compared to MDCT. (Echocardiography 2012;29:735‐741)     

Outcomes of medically treated patients with aortic intramural hematoma

PURPOSE: Aortic intramural hematoma has been considered a precursor of aortic dissection, and the same treatment strategy, usually involving surgery, has been applied to both conditions. However, the outcomes of patients with aortic intramural hematoma who are treated medically, including the remodeling process that occurs after an acute event, are not known. SUBJECT AND METHODS: A total of 124 patients with acute aortic intramural hematoma (41 in the proximal aorta and 83 in the distal aorta) was enrolled from five institutions in South Korea. Patients received medical treatment without surgery. A follow-up imaging study was performed in 105 patients. RESULTS: Pericardial (59% [n = 24] vs. 11% [n = 9], P <0.004) and pleural effusions (63% [n = 26] vs. 45% [n = 37], P = 0.05) were more common in patients with the proximal type than in those with the distal type. In-hospital mortality was somewhat higher with proximal hematomas (7% [n = 3 deaths] vs. 1% [n = 1 death], P = 0.11). A follow-up imaging study in 36 patients with proximal hematomas confirmed resorption of the hematoma in 24 patients (67%) and development of aortic dissection in 9 (25%). Resorption was confirmed in 54 (78%) of the 69 patients with distal hematomas who underwent follow-up imaging; localized aortic dissection developed in 11 (16%) of these patients. The 3-year survival rate was 78% in the proximal type and 87% in the distal type (P = 0.10). CONCLUSION: Patients with aortic intramural hematoma had a high rate of resorption with medical treatment regardless of the affected site. Further investigation is necessary to determine the optimal treatment strategy and timing of surgical intervention, especially for patients with proximal hematomas.     

Note the descending aorta: predictors of postoperative major adverse aortic event in pure acute type A intramural hematoma

BackgroundIntramural hematomas (IMHs) may originate from small intimal tears. Although most surgeries for acute type A IMH are conventionally performed solely at the proximal aorta, regardless of the primary intimal tear site, the remnant aortic remodeling stays important during the follow-up period after surgery.MethodsForty-seven patients with “pure” acute type A IMHs who underwent surgery from January 2008 to December 2019 were retrospectively analyzed. Acute type A IMH in the entire region without penetrating aortic ulcer (PAU) and aortic dissection (AD), which upon initial computed tomography (CT), can be considered as an intimal tear site, was defined as “pure” type. The maximal diameter of the aorta, maximal thickness of the IMH, and hematoma thickness ratio (HTR) of the ascending and descending aortae were measured from the preoperative computed tomographic scan. The hematoma thickness index was defined as the HTR of the descending aorta divided by that of the ascending aorta. Major adverse aortic events (MAAEs) were defined as AD, rupture, or newly developed PAU and aortic death. Predictors for postoperative MAAEs were analyzed using preoperative computed tomographic findings.ResultsThe measurements of the descending aorta were larger and those of the ascending aorta were smaller in the MAAEs group, than in the corresponding other. The hematoma thickness index was significantly higher in the group with MAAEs, than in the group without; this variable was an independent predictor of MAAEs. During surgery, intimal tears were found in 16/47 (34%) patients. The hematoma thickness index was significantly smaller in the group with intimal tears than in the group without the tears. The aortic measurement appears to reflect the tear site.ConclusionsHematoma thickness index was an independent predictor of MAAE after acute type A IMH surgery. Long-term periodical follow-up with early reintervention may, therefore, be necessary to improve outcome in these patients. As the optimal treatment method is still controversial, inferring the location of the primary tear through the hematoma thickness index can be helpful in determining the treatment method.     

A case of complete double aortic arch visualized by transthoracic echocardiography

A case of double aortic arch that was well visualized using transthoracic echocardiography is reported. A 38‐year‐old man underwent transthoracic echocardiography for the evaluation of dyspnea. A suprasternal view of transthoracic echocardiography showed the ascending aorta bifurcate to left and right aortic arches, with blood flow from the ascending aorta to bilateral aortic arches. The diagnosis of right side–dominant double aortic arch was made, and the patient's symptom was conceivably related to compression of the trachea due to a vascular ring. This report indicates the potential usefulness of transthoracic echocardiography for noninvasive detection of double aortic arch in adults.     

Ulcer-like projections into the dilated false lumen after stent-graft placement for aortic dissection: A case report

Rationale:Acute type A aortic dissection and chronic type B aortic dissection (TBAD) occurs simultaneously in rare cases. Although the development of ulcer-like projection (ULP) is associated with an increase in adverse aorta-related events, the false-lumen enlargement caused by the ULP progression is uncommon.Patient concerns:A 72-year-old female with chronic TBAD was admitted to our unit with back and chest pain. Computed tomography revealed acute type A aortic dissection and a hematoma caused by rupturing of the descending aorta due to chronic TBAD. After endovascular intervention, the false lumen thrombosed and shrunk.Diagnosis:After 9 months, a developing ULP, which projected into a dilating false lumen, was found. An impending ruptured descending aortic aneurysm was confirmed.Interventions:Emergency Total arch replacement and thoracic endovascular aortic repair (TEVAR) was performed.Outcomes:The procedure was successful. One year later, regular follow-up showed that the false lumen had completely shrunk.Lessons:ULP can arise and cause progressive dilation of false lumen after TEVAR. Careful and regular computed tomography examinations are required for early diagnosis of false lumen becoming thrombosed after TEVAR. Close follow-up and timely intervention, including TEVAR, should be considered in cases of aortic enlargement due to a newly developed ULP.     

The potential value of intravascular ultrasound imaging in diagnosis of aortic intramural hematoma

Objective To evaluate the potential value of intravascular ultrasound (IVUS) imaging in the diagnosis of aortic intramural hematoma (AIH). Methods From September 2002 to May 2005, a consecutive series of 15 patients with suspected aortic dissection (AD) underwent both IVUS imaging and spiral computed tomography (CT). Six patients diagnosed as acute type B AIH by CT or IVUS composed the present study group. Results The study group consisted of five males and one female with mean age of 66 years old. All of them had chest or back pain. In one patient, CT omitted a localized AIH and an associated penetrating atherosclerotic ulcer (PAU), which were detected by IVUS. In another patient, CT mistaken a partly thrombosed false lumen as an AIH, whereas IVUS detected a subtle intimal tear and slow moving blood in the false lumen. In the four rest patients, both CT and IVUS made the diagnosis of AIH, however, IVUS detected three PAUs in three of them, only one of them was also detected by CT, and two of them escaped initial CT and were confirmed by follow up CT or magnetic resonance imaging. Conclusions IVUS imaging is a safe examination and has high accuracy in the diagnosis of AIH, particularly for diagnosing localized AIH, distinguishing AIH with thrombosed classic AD and detecting accompanied small PAUs.     

Live three-dimensional transthoracic echocardiographic assessment of aortic dissection

In the present study, we report our experience of using live three-dimensional transthoracic echocardiography in the assessment of aortic dissection in ten adult patients. To our knowledge, this has not been reported previously.     

Thoracic endovascular aortic repair and optimal medical treatment for acute type B penetrating aortic ulcer associated with intramural hematoma

To compare the safety and efficacy of thoracic endovascular aortic repair (TEVAR) and optimal medical treatment (OMT) for type B penetrating aortic ulcer (PAU) associated with intramural hematoma (IMH). From January 2015 to December 2018, 68 consecutive patients with acute type B PAU associated with IMH were enrolled in the study. TEVAR was performed following initially OMT in 30 patients (group A), and OMT was performed in 38 patients (group B). Primary outcome was aortic-related mortality. Secondary outcomes included all-cause mortality, aortic-related adverse events, and complete aortic remodeling. There was no significant difference in the baseline characteristics of patients among the 2 groups except for the depth of PAU and the thickness of IMH. Patients in group B had a significant higher risk of aortic-related mortality (13.3% vs 0%, P = .045), as the same to aortic-related adverse events during follow-up. Compared to OMT, TEVAR contributed to the favorable aortic remodeling more significantly during the mid-term follow-up (85.7% vs 18.2%, P < .001). Comparing with optimal medical repair, TEVAR for patients with PAU associated with IMH could promote the favorable aortic remolding more significantly and result in lower aortic-related mortality during mid-term follow-up. It should be considered as the first-line therapeutic option when intervention is required.     

Achalasia combined with esophageal intramural hematoma: case report and literature review

A 62-year-old male patient was admitted to our hospital due to severe chest pain,odynophagia,and hematemesis.Chest computed tomography showed an esophageal submucosal tumor.Esophagogastroduodenoscopy(EGD) revealed a longitudinal purplish bulging tumor of the esophagus.Endoscopic ultrasound(EUS) showed a mixed echoic tumor with partial liquefaction from the submucosal layer.The patient was diagnosed with esophageal intramural hematoma as well as achalasia by upper gastrointestinal endoscopy,esophagography an...