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Correspondence

Thrombosed-Type Acute Aortic Dissection

Department of Cardiovascular Surgery, Shizuoka Medical Center, 762-1 Nagasawa, Shimizu-cho, Sunto-gun, Shizuoka, 411-8611 Japan

(Email: kfgth973{at}ybb.ne.jp).

To the Editor:

On the basis of intraoperative findings, Park and associates [1] showed that the prevalence of intimal tear in the ascending aorta or arch is high (73.0%) in the patients who were diagnosed as Stanford type A acute aortic intramural hematoma (IMH) by conventional definition (ie, the presence of concentric space in the ascending aortic wall that was not enhanced by a contrast agent in the computed tomographic scan taken within 48 hours after symptom onset). Generally it is believed that IMH is caused by rupture of the vasa vasorum in the media without intimal tear in accidents [2, 3], since it was first proposed by Krukenberg [4] in 1920. Meanwhile, in Japan, the term thrombosed-type acute aortic dissection (AAD) [5–7] has been preferably substituted for IMH. Unlike the hypothesis of vasa vasorum rupture without intimal tear, it has been considered that thrombosed-type AAD is caused by false lumen thrombosis immediately after the intimal tear (entry) develops the same as in classic AAD because of static flow in it, probably due to the absence of any re-entry. As a piece of evidence to support the thrombosed-type hypothesis, besides ulcer-like projection (a trace of entry according to the hypothesis) mentioned by Park and colleagues [1], we could display the false lumen compressing the true lumen in IMH on computed tomographic scan (Fig 1). If vasa vasorum rupture without intimal tear caused the false lumen, the false lumen pressure equivalent to the vasa vasorum pressure would be much lower than the true lumen pressure equal to the aortic pressure, and the false lumen would never compress the true lumen. According to the thrombosed-type hypothesis, the false lumen (even though it is thrombosed) is directly exposed to the aortic pressure through the entry because it is a dead-end due to the absence of any re entry, which could compress the true lumen. The thrombosed-type hypothesis supports Park and coworkers' [1] conclusion that a large proportion of IMH may have a similar pathogenic mechanism as classic AAD, and the conventional definition of IMH should be changed. Furthermore, regarding IMH with ulcer-like projection or the false lumen compressing true lumen, we would like to propose that the terms of thrombosed-type AAD be substituted for that of acute aortic IMH.

View larger version (62K): [in this window] [in a new window]   Fig 1. The false lumen compresses the true lumen in the intramural hematoma on the computed tomographic scan.

	References

Top References

 

1. Park KH, Lim C, Choi JH, et al. Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma Ann Thorac Surg 2008;86:1494-1500.[Abstract/Free Full Text]
2. Sawhney NS, DeMaria AN, Blanchard DG. Aortic intramural hematoma: an increasingly recognized and potentially fatal entity Chest 2001;120:1340-1346.[Abstract/Free Full Text]
3. Song JK. Diagnosis of aortic intramural haematoma Heart 2004;90:368-371.[Free Full Text]
4. Krukenberg E. Beitrage zur Frage des Aneurysma dissecans Beitr Pathol Anat Allg Pathol 1920;67:329-351.
5. Matsuo H. The thrombosed type of aortic dissection-its clinical features and diagnosis Int J Angiol 1998;7:329-334.[Medline]
6. Matsuo H. Recognition and management of thrombosed type of aortic dissection with long-term follow-up results Int J Angiol 2000;9:27-30.[Medline]
7. Kurimoto Y, Morishita K, Kawaharada N, Fukada J, Asai Y, Abe T. Initial management of acute type-A aortic dissection with a thrombosed false lumen: a retrospective cohort study Surg Today 2004;34:652-657.[Medline]

This article has been cited by other articles:

				K.-H. Park Reply Ann. Thorac. Surg., October 1, 2009; 88(4): 1389 - 1390. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hisato Takagi Takuya Umemoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Takagi, H. Articles by Umemoto, T. Search for Related Content PubMed PubMed Citation Articles by Takagi, H. Articles by Umemoto, T. Related Collections Great vessels Related Article