Ann Thorac Surg 2008;86:456-457. doi:10.1016/j.athoracsur.2008.04.079
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Eugenio Neri, MD
Unità Operativa di Chirurgia dell'Aorta Toracica, Policlinico "Santa Maria alle Scotte", Viale M. Bracci, Siena, 53100 Italy
(Email: euxneri{at}tin.it; nerie{at}unisi.it).
Although many consider intramural hematoma (IMH) to be a variant of aortic dissection, the pathogenesis still remains unclear. First described by Krukenberg [1] in 1920, IMH is defined as bleeding into the outer layers of the aortic media from rupture of the vasa-vasorum without a primary intimal tear. Despite the increased in vivo recognition of IMH, an aura of uncertainty and mystery surrounds this clinical entity [2]. However, this confusion should not involve the definition of IMH, which is clear and unambiguous.
In recent years, powerful vascular imaging techniques demonstrated a wide spectrum of lesions associated to medial blood extravasation in vivo. These images have created in our literature ambiguity between the "classical" definition of IMH (based on autopsy series) and an IMH that may accompany other conditions, such as penetrating aortic ulcers (PAU) or aortic dissections (ie, noncommunicating aortic dissections). The need to re-define traditional clinical concepts in light of modernimaging techniques led Ganaha and colleagues [3] to introduce a separation of aortic IMHs into those with or without penetrating atherosclerotic ulcers. At the moment, there is a lack of agreement in the definition of IMH and PAU; therefore, a new consensus regarding definitions is needed. These definitions should always be clear and functional; therefore, wringing new meaning out of old words is only justifiable if it contributes to better understanding.
This article by Grimm and colleagues [4] is an example of the deleterious consequences of our current confusion. The article describes interesting observations regarding the relationships between the localization of plaques within the aortic arch, and progression of the IMH. However, it is clear that these patients do not have "classical" IMHs. This ambiguity raises the possibility of an endovascular option for IMHs, but these lesions are not IMHs and penetrating aortic ulcers are already treated by endovascular means [5].
This unfortunate use of terms transforms this honest, although limited, series of PAUs treated by stent grafts, into something different. The result is deceiving and puzzling but urges all of us to reflect; should we preserve a trustworthy definition born on the autopsy table almost 90 years ago or adopt new definitions based on radiologic images?
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References
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- Krukenberg E. Beitrage zu frage des aneurysma dissecans Beitr Pathol Anat Allg Pathol 1920;67:329-351.
- Evangelista A, Mukherjee D, Mehta RH, et al. Acute intramural hematoma of the aorta: a mystery in evolution Circulation 2005;111:1063-1070.[Abstract/Free Full Text]
- Ganaha F, Miller DC, Sugimoto K, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis Circulation 2002;106:342-348.[Abstract/Free Full Text]
- Grimm M, Loewe C, Gottardi R, et al. Novel insights into the mechanisms and treatment of intramural hematoma affecting the entire thoracic aorta Ann Thorac Surg 2008;86:453-457.[Abstract/Free Full Text]
- Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts Ann Thorac Surg 2008;85(Suppl 1):S1-S41.[Abstract/Free Full Text]
Related Article
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Novel Insights Into the Mechanisms and Treatment of Intramural Hematoma Affecting the Entire Thoracic Aorta
- Michael Grimm, Christian Loewe, Roman Gottardi, Martin Funovics, Daniel Zimpfer, Suzanne Rodler, Marion Dorfmeister, Maria Schoder, Johannes Lammer, Seyedhossein Aharinejad, and Martin Czerny
Ann. Thorac. Surg. 2008 86: 453-456.
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