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Penetrating ulcers of the aorta, aortic dissections, and intramural hematomas (IMH) all fall under acute aortic syndromes (AAS) and have important similarities and differences. We present a case of an asymptomatic patient with uncontrolled hypertension who was found to have a unique combination of penetrating aortic ulcers (PAUs) with an associated IMH. Furthermore, the patient had PAUs located in the aortic arch, which is an uncommon since the majority are located in the descending thoracic aorta. His PAUs and IMH progressed despite medical management and subsequently required thoracic endovascular aortic repair (TEVAR). The treatment of IMHs and PAUs is less well known compared to the classic aortic dissection. Often, they may not be treated as an AAS or may be treated as an aortic dissection. This case report addresses this challenge clinicians face with unclear delineation of treatment between different AAS. This case demonstrates how a type B IMH, when associated with penetrating ulcers, may follow a more malignant course, and should be considered for early surgical intervention. This case illustrates the importance of understanding the distinction between the AAS and how treatment differs based on Stanford classification and risk factors of progression.

Progression of aortic intramural hematoma with associated penetrating aortic ulcers with medical management requiring surgical management case report