Abdominal aortic intramural Hematoma related to penetrating ulcer: An inappropriate indication for endovascular repair?

Purpose: To present a rare case of abdominal aortic intramural hematoma with penetrating ulcer. Case Report: A 68-year-old hypertensive lady was admitted with chest pain. An echo Doppler abdominal study showed a 2.5-cm-diameter abdominal aorta with periaortic blood flow. Urgent computed tomography documented a 4-cm aneurysmal dilatation, 4 cm long, at the infrarenal level of the inferior mesenteric artery origin, which appeared on the angiogram as a very short lateral bleb. At elective open laparotomy, no true abdominal atherosclerotic aneurysm was found in the retroperitoneal space, but rather, an intramural hematoma with ulcer. An aortobi-iliac graft was inserted, and the patient was discharged with a good outcome. Histological examination of the explanted tissue confirmed adventitial calcifications, organized thrombus in the hematoma, and intimal neovascularization. Conclusions: Considering the pathology, this case was more appropriately treated with open surgery, although endovascular repair was not excluded as an option.