Acute retrograde type A intramural hematoma during severe acute respiratory syndrome coronavirus 2 pandemic

Abstract

Acute intramural hematomas (IMHs) occur in ∼6% of patients with acute dissections (ADs) and mostly affect the descending aorta.1Harris K.M. Braverman A.C. Eagle K.A. Woznicki E.M. Reed E.P. Myrmel T. et al.Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection.Circulation. 2012; 126: S91-S96Crossref PubMed Scopus (147) Google Scholar Type A IMHs involve the ascending aorta and type B IMHs do not involve the ascending aorta. Retrograde type A IMHs (retro-TAIMHs) originate in the descending aorta and extend into the arch or ascending aorta. TAIMHs with distal AD carry an in-hospital mortality risk of 12% to 26%.1Harris K.M. Braverman A.C. Eagle K.A. Woznicki E.M. Reed E.P. Myrmel T. et al.Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection.Circulation. 2012; 126: S91-S96Crossref PubMed Scopus (147) Google Scholar,2Tolenaar J.L. Harris K.M. Upchurch Jr., G.R. Evangelista A. Moll F.L. Di Eusnio M. et al.The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection.J Vasc Surg. 2013; 58: 1498-1504Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar We report the case of an 85-year-old woman with acute retro-TAIMH and distal AD. The patient provided consent for the report of her case. She was admitted to the emergency room with acute onset dyspnea and chest pain but no evidence of malperfusion. Emergency computed tomography angiography identified a retro-TAIMH with AD and a proximal entry tear above the celiac axis (A/Cover). The patient was hemodynamically stable. She was treated with hypotensive and analgesic therapy and hospitalized for intensive monitoring. Follow-up computed tomography angiography was performed at 24 hours (B) and 7 days (C) showing progressive to complete thrombosis of the entry tear, with a reduction in the aortic diameter, the most important predictor of IMH regression and positive outcomes.3Evangelista A. Dominguez R. Sebastia C. Salas A. Permanyer-Miralda G. Avegliano G. et al.Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma: therapeutic implications.Eur Heart J. 2004; 25: 81-87Crossref PubMed Scopus (100) Google Scholar Complete symptom regression occurred. The event was observed during the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in Lombardy, Italy. The patient had tested positive for SARS-CoV-2 at 5 days after symptom onset, with progressive dyspnea and worsening findings on a chest radiograph (D). She died of pulmonary complications at 19 days postoperatively. Hybrid treatment with ascending aortic replacement and distal thoracic aortic endovascular repair (TEVAR) or using the frozen elephant trunk procedure is the most appropriate treatment for acute retro-TAIMH. TEVAR is a valid alternative only for patients with prohibitive surgical risk, although the landing zones could be unsuitable and the risk of neurologic and cardiac complications can be high.4Nauta F. De Beaufort H. Mussa F.F. De Vincentiis C. Omura A. Matsuda H. et al.Management of retrograde type A IMH with acute arch tear/type B dissection.Ann Cardiothorac Surg. 2019; 8: 531-539Crossref PubMed Scopus (7) Google Scholar Medical treatment appears to be appropriate for asymptomatic patients, those with noncomplicated retro-TAIMHs, and patients with high open surgical and TEVAR risks.4Nauta F. De Beaufort H. Mussa F.F. De Vincentiis C. Omura A. Matsuda H. et al.Management of retrograde type A IMH with acute arch tear/type B dissection.Ann Cardiothorac Surg. 2019; 8: 531-539Crossref PubMed Scopus (7) Google Scholar Considering both the absence of end-organ malperfusion and the advanced age of our patient, we chose medical treatment, which can reduce mortality by 67% to 95%.5Ince H. Nienaber C.A. Diagnosis and management of patients with aortic dissection.Heart. 2007; 93: 266-270Crossref PubMed Scopus (60) Google Scholar This choice proved effective with symptom recovery and clinical stability of the present patient, until the deadly overlap of SARS-CoV-2. Toward a unified pathophysiology in COVID-19 acute aortopathiesJournal of Vascular SurgeryVol. 74Issue 5PreviewThe interesting article by Katsarou et al1 about aortic intramural hematoma complicating a severe acute respiratory disease coronavirus 2 (SARS-CoV-2) infection is compelling, and its pathophysiology needs to be elucidated further. Full-Text PDF