key: cord-1010401-wmbgpnr9
authors: Katsarou, Maria; Grassi, Viviana; Lomazzi, Chiara; Domanin, Maurizio; Trimarchi, Santi
title: Acute Retrograde Type A Intramural Hematoma during SARS-CoV-2 time
date: 2020-10-15
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.09.019
sha: 0c13a28579f3205c4a9e7e17720b033486badc43
doc_id: 1010401
cord_uid: wmbgpnr9

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mostly affecting the descending aorta. 1 Type A IMHs involve, type B IMHs do not involve the 3 ascending aorta. Retrograde type A IMH (retro-TAIMH) origins in the descending aorta and 4 extend into the arch or ascending aorta. TAIMHs with distal AD carry an in-hospital mortality 5 risk of 12-26%. 1-2 6

We report the case of an 85-year-old woman with acute retro-TAIMH and distal AD. The 7 patient's consent for publication was obtained. She was admitted to the emergency room with 8 acute onset dyspnea, chest pain but no evidence of malperfusion. Emergency Computed 9

Tomography Angiography (CTA) identified a retro-TAIMH with AD with proximal entry tear 10 above the celiac axis (A/Cover). 11

The patient was hemodynamically stable. She was treated with hypotensive and analgesic 12 therapy and hospitalized for intensive monitoring. Follow-up CTA was performed at 24 hours 13 (B) and 7 days (C) showing progressive to complete thrombosis of the entry tear, with reduction 14 in aortic diameter which is the most important predictor of IMH regression and positive 15 outcome. 3 Complete symptom regression occurred. The event was observed during the SARS-16

CoV-2 pandemic peak in Lombardy and the patient was found to be positive to the virus five 17 days after symptom onset, with progressive dyspnea and worsening findings on chest X rays (D). 18

She died due to pulmonary complications at 19 days. 19

Hybrid treatment with ascending aortic replacement and distal thoracic aortic endovascular 20 repair (TEVAR), or with Frozen Elephant Trunk is the most appropriate treatment for acute 21 retro-TAIMH. TEVAR is a valid alternative only in patients with prohibitive surgical risk, 22

although landing zones may be unsuitable and the risk of neurological and cardiac complications 23 may be high. 4 Medical treatment appears to be appropriate in asymptomatic patients, in those 1 with non-complicated retro-TAIMH and in patients with high open surgical / TEVAR risks. 4 

Considering both the absence of end-organ malperfusion and the advanced age of the patient, we 3 chose medical treatment, that allows to reduce mortality by 67-95%. 5 This choice was proven 4 effective with symptom recovery and clinical stability, until the deadly overlap of the SARS-5

CoV-2. 6 J o u r n a l P r e -p r o o f

The differences and similarities between intramural hematoma of the descending 6 aorta and acute type B dissection

Prognostic value of clinical and morphologic findings in short-10 term evolution of aortic intramural haematoma. Therapeutic implications

Management of retrograde type A IMH with acute arch tear/type B dissection

Diagnosis and management of patients with aortic dissection