Type B intramural hematoma: thoracic endovascular aortic repair (TEVAR) or conservative approach?

An intramural hematoma (IMH) is the second most common presentation of acute aortic syndrome, with an estimated occurrence of 1.98/100,000 person-years (1). In the majority of cases, an IMH is located in the descending thoracic aorta. The clinical symptoms are similar to those of aortic dissection (AD), yet the population is older, the morphology different, and the mortality rate lower compared to AD. IMH was first described by Krukenberg in 1920 (2). Ever since, the pathophysiology of the disease is yet to be elucidated. We currently have only retrospective series available to describe the natural history. This is partly due to relatively low incidence of the disease itself. The onset of IMH has been associated with the occurrence of intimal micro-tears, vasa-vasorum hemorrhage and undiscovered penetrating atherosclerotic ulcers (PAU) (3,4).