Hybrid Repair of Ascending Aortic Intramural Hematoma and Arch Ulcer in a 74-Year-Old Woman – A Case Report

BACKGROUND Acute intramural hematoma (IMH) of the ascending thoracic aorta and aortic arch is a life-threatening condition, particularly in elderly patients with comorbidities, due to its risk of progression and rupture. Unlike aortic dissection, IMH lacks an intimal tear, influencing both clinical presentation and treatment strategy. This report describes a 74-year-old hypertensive woman with type A IMH and a penetrating atherosclerotic ulcer (PAU), managed with a hybrid surgical approach that combines external Dacron wrapping of the ascending aorta and endovascular stenting of the aortic arch with in-situ fenestration of the supra-aortic arteries. CASE REPORT A 74-year-old woman with a history of hypertension, insulin-dependent diabetes, chronic kidney disease, coronary artery disease, and extracardiac arteriopathy presented with chest pain and was diagnosed with type A IMH. Cardiac assessment showed a moderate left ventricular ejection fraction (45%) and New York Heart Association class III functional status, indicating high surgical risk (EuroSCORE II: 11.66). A hybrid approach was chosen, involving Dacron wrapping of the ascending aorta to reduce its diameter, followed by endovascular stent grafting of the aortic arch with in-situ fenestration to preserve supra-aortic branch blood flow. The patient recovered without complications, and 5-month follow-up imaging confirmed stable stent position, PAU exclusion, and preserved branch patency. CONCLUSIONS This case illustrates the feasibility and safety of combining off-pump external wrapping of the ascending aorta with endovascular stent grafting using in-situ fenestration, offering a promising, less-invasive alternative for high-risk patients with favorable short-term outcomes.