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      Misdiagnosed Aortic Intramural Hematoma and the Role of Intravascular Ultrasound Imaging in Detection of Acute Aortic Syndrome: A Case Report

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          Abstract

          Acute aortic syndrome includes classic aortic dissection, aortic intramural hematoma, and penetrating atherosclerotic ulcer – a group of conditions that are defined by their dynamic evolution and similar clinical manifestation. Accurate diagnosis and prompt treatment are essential as all the aforementioned conditions are a significant threat to a patient’s life. However, acute aortic syndrome and especially aortic intramural hematoma may be challenging diagnostic problems. Intravascular ultrasound imaging is a diagnostic method that can be useful for more thorough evaluation of the aortic lesion and can particularly aid in discerning the different forms of acute aortic syndrome. We present a case of a patient with aortic intramural hematoma that was missed by conventional imaging studies but was successfully visualized with intravascular ultrasound imaging.

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          Acute aortic dissection.

          We summarise advances in the epidemiology, presentation, pathogenesis, diagnosis, and management of acute aortic dissection. Improved understanding of this problem has been assisted not only by establishment of an international registry but also by progress in molecular biology and genetics of connective-tissue diseases. Advances in endovascular products and techniques have provided new treatment options. Open surgical repair remains the main treatment for dissection in the ascending aorta, whereas endovascular treatment is increasingly being used in dissection that is limited to other parts of the aorta.
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            Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques.

            The modern imaging techniques of transesophageal echocardiography, CT, and MRI are reported to have up to 100% sensitivity in detecting the classic class of aortic dissection; however, anecdotal reports of patient deaths from a missed diagnosis of subtle classes of variants are increasingly being noted. In a series of 181 consecutive patients who had ascending or aortic arch repairs, 9 patients (5%) had subtle aortic dissection not diagnosed preoperatively. All preoperative studies in patients with missed aortic dissection were reviewed in detail. All 9 patients (2 with Marfan syndrome, 1 with Takayasu's disease) with undiagnosed aortic dissection had undergone >/=3 imaging techniques, with the finding of ascending aortic dilatation (4.7 to 9 cm) in all 9 and significant aortic valve regurgitation in 7. In 6 patients, an eccentric ascending aortic bulge was present but not diagnostic of aortic dissection on aortography. At operation, aortic dissection tears were limited in extent and involved the intima without extensive undermining of the intima or an intimal "flap." Eight had composite valve grafts inserted, and all survived. Of the larger series of 181 patients, 98% (179 of 181) were 30-day survivors. In patients with suspected aortic dissection not proven by modern noninvasive imaging techniques, further study should be performed, including multiple views of the ascending aorta by aortography. If patients have an ascending aneurysm, particularly if eccentric on aortography and associated with aortic valve regurgitation, an urgent surgical repair should be considered, with excellent results expected.
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              Acute aortic syndrome.

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                Author and article information

                Journal
                CVIA
                Cardiovascular Innovations and Applications
                CVIA
                Compuscript (Ireland )
                2009-8782
                2009-8618
                January 2018
                March 2018
                : 2
                : 4
                : 447-449
                Affiliations
                1Cardiology Clinic, “Alexandrovska” University Hospital, Medical University of Sofia, “St. George Sofiiski” Str. 1, 1431 Sofia, Bulgaria
                2Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland; and Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
                3Cardiovascular Diagnosis and Endoluminal Interventions, Section of Adult Congenital Heart Interventions, Rovigo General Hospital, Rovigo, Italy
                Author notes
                Correspondence: Niya Mileva, MD, Cardiology Clinic, “Alexandrovska” University Hospital, Medical University of Sofia, “St. George Sofiiski” Str. 1, 1431 Sofia, Bulgaria, E-mail: nmileva91@ 123456gmail.com
                Article
                cvia20170028
                10.15212/CVIA.2017.0028
                Copyright © 2018 Cardiovascular Innovations and Applications

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

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