Limited intimal tears (LITs) are uncommon but potentially lethal lesions within the dissection spectrum, occurring in approximately 5% of patients presenting with acute aortic syndrome (1). LITs are classified as a “class 3 of intimal tear” and represented by intimomedial tears with an eccentric aortic wall bulge but without substantial hematoma (2). While the edges of an LIT can be undermined to a variable degree and filled with small amounts of blood or clot, there is no propagation of the dissection plane along the aorta and no exit tear and double-barrel flow channel as in classic aortic dissection (1,3). LITs may evade identification at transesophageal echocardiography or CT because of the limited extent of undermined intimal layers and a minimal amount of blood in the dissected aortic wall. This imaging pitfall can result in progression of dissection, cardiac tamponade, or aortic rupture causing potentially lethal outcomes (1,2,4). Furthermore, the diagnosis of LITs may be missed if conventional diagnostic criteria that are dependent on the presence of an intimal flap are applied (4). Awareness of this entity, high index of suspicion at CT angiography with use of appropriate reconstruction techniques for the aortic root may allow timely patient management (1) (Figure).
Images in a 62-year-old man who presented to the emergency department with acute chest pain. (A) Short-axis view of the aortic root, (B) three-chamber view, (C–E) three-dimensional volume-rendered images, and (F) intraoperative view after median sternotomy with extracorporeal circulation show an eccentric bulge of the right aortic sinus (R) with the presence of a focal limited tear (arrowhead). This is represented by focal linear “flaps” with undermined edges, as a bandlike outpouching where the right coronary artery (RCA) took off. The patient underwent graft replacement of the ascending aorta and aortic valve replacement. AA = ascending aorta, LA = left atrium, LV = left ventricle, LM = left main artery, R/L/NC = right/left/noncoronary aortic sinus.
Footnotes
Authors declared no funding for this work.
Disclosures of conflicts of interest: L.d.P.G.d.F. No relevant relationships. M.C.S. No relevant relationships. J.H.d.A.P.d.F. No relevant relationships. L.d.P.S.B. No relevant relationships.
Keywords: CT Angiography, Vascular, Aortic Root
References
- 1. Chin AS , Willemink MJ , Kino A , et al . Acute limited intimal tears of the thoracic aorta . J Am Coll Cardiol 2018. ; 71 ( 24 ): 2773 – 2785 . [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Hiratzka LF , Bakris GL , Beckman JA , et al . 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine . J Am Coll Cardiol 2010. ; 55 ( 14 ): e27 – e129 . [DOI] [PubMed] [Google Scholar]
- 3. Murray CA , Edwards JE . Spontaneous laceration of ascending aorta . Circulation 1973. ; 47 ( 4 ): 848 – 858 . [DOI] [PubMed] [Google Scholar]
- 4. Svensson LG , Labib SB , Eisenhauer AC , Butterly JR . Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques . Circulation 1999. ; 99 ( 10 ): 1331 – 1336 . [DOI] [PubMed] [Google Scholar]