Precipitous Resolution of Type-A Intramural Hematoma with Medical Management in a Patient with Metastatic Stage 4 Renal Cell Carcinoma

Abstract

Intramural hematoma (IMH) is a variant form of aortic dissection characterized by involvement of the aortic media without the presence of an overt intimal flap. Surgical extirpation is the standard of care for type-A IMH in the Western world. However, a conservative approach with anti-impulse therapy has been advocated especially in Japan as a viable alternative. Here, we report a case of an elderly male patient with a history of metastatic stage 4 renal cell carcinoma who was treated with anti-impulse therapy for an acute type-A IMH. Blood pressure stabilization and continuous monitoring resulted in complete resolution of the IMH within 6 days. This report illustrates how immediate medical management in patients with acute type-A IMH who are not surgical candidates can alleviate the progression or even lead to regression as early as 1 week after initiating anti-impulse therapy.

Keywords

dissection - dissecting aneurysm - hematoma - intramural hematoma - medical therapy - resolution - type-A dissection

• References

• 1 Corvera JS. Acute aortic syndrome. Ann Cardiothorac Surg 2016; 5 (03) 188-193
• 2 Nienaber CA, Clough RE, Sakalihasan N. , et al. Aortic dissection. Nat Rev Dis Primers 2016; 2: 16053
• 3 Song JK. Aortic intramural hematoma: aspects of pathogenesis 2011. Herz 2011; 36 (06) 488-497
• 4 Chou AS, Ziganshin BA, Charilaou P, Tranquilli M, Rizzo JA, Elefteriades JA. Long-term behavior of aortic intramural hematomas and penetrating ulcers. J Thorac Cardiovasc Surg 2016; 151 (02) 361-372 , 373.e1
• 5 Hoey ET, Wai D, Ganeshan A, Watkin RW. Aortic intramural haematoma: pathogenesis, clinical features and imaging evaluation. Postgrad Med J 2012; 88 (1045): 661-667
• 6 Bonaca MP, O'Gara PT. Diagnosis and management of acute aortic syndromes: dissection, intramural hematoma, and penetrating aortic ulcer. Curr Cardiol Rep 2014; 16 (10) 536
• 7 Estrera A, Miller III C, Lee TY. , et al. Acute type A intramural hematoma: analysis of current management strategy. Circulation 2009; 120 (11, Suppl): S287-S291
• 8 Song JK, Kim HS, Song JM. , et al. Outcomes of medically treated patients with aortic intramural hematoma. Am J Med 2002; 113 (03) 181-187
• 9 Ho HH, Cheung CW, Jim MH. , et al. Type A aortic intramural hematoma: clinical features and outcomes in Chinese patients. Clin Cardiol 2011; 34 (03) E1-E5
• 10 Tittle SL, Lynch RJ, Cole PE. , et al. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta. J Thorac Cardiovasc Surg 2002; 123 (06) 1051-1059
• 11 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 (05) 1494-1500
• 12 Uchida K, Imoto K, Karube N. , et al. Intramural haematoma should be referred to as thrombosed-type aortic dissection. Eur J Cardiothorac Surg 2013; 44 (02) 366-369 , discussion 369
• 13 Henn MC, Lawrance CP, Braverman AC, Sanchez L, Lawton JS. Medical and Surgical Management of a Descending Aorta Penetrating Atherosclerotic Ulcer and Associated Ascending Intramural Hematoma. Aorta (Stamford) 2014; 2 (02) 77-81
• 14 Moizumi Y, Komatsu T, Motoyoshi N, Tabayashi K. Management of patients with intramural hematoma involving the ascending aorta. J Thorac Cardiovasc Surg 2002; 124 (05) 918-924
• 15 Choueiri TK, Motzer RJ. Systemic therapy for metastatic renal-cell carcinoma. N Engl J Med 2017; 376 (04) 354-366
• 16 Ohmi M, Tabayashi K, Moizumi Y, Komatsu T, Sekino Y, Goko C. Extremely rapid regression of aortic intramural hematoma. J Thorac Cardiovasc Surg 1999; 118 (05) 968-969