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Alberts et al. Vessel Plus 2023;7:34 https://dx.doi.org/10.20517/2574-1209.2023.37 Page 13 of 24

Iatrogenic intramural hematoma is a rare complication and has been described in literature in some case
reports. In the perioperative setting, it can be caused by placement or manipulation of the aortic cannulas or
[77]
by aortic cross-clamping . Furthermore, it has been described to be caused by retrograde coronary
[78]
dissection into the aortic root during percutaneous coronary interventions . The echocardiographic
assessment of iatrogenic IMH is similar to spontaneous IMH. It can be challenging to distinguish iatrogenic
IMH from IAD [78,79] .

Penetrating aortic ulcer
A penetrating aortic ulcer (PAU) occurs when an aortic atherosclerotic plaque ulcerates through the intima
into the media of the aortic wall. It occurs predominantly in the descending aorta and less frequently in the
[18]
aortic arch . PAU can lead to an intramural hematoma, AD, aortic aneurysm, or rupture, if the adventitia
[68]
is affected . PAU appears on TEE as a focal, outpouching lesion with a rough, serrated edge [68,74] [Figure 9].
In the acute phase, it is frequently accompanied by hematoma localized around the lesion .
[74]
Traumatic aortic injury/aortic rupture
Traumatic aortic injury (TAI) most often occurs in blunt trauma or deceleration injuries. It can result in a
variety of lesions, including AD, IMH, (pseudo)aneurysm formation, or (contained) rupture [18,62,80] .

Aortic rupture is characterized as a disruption of all the aortic wall layers, leading to an acute, devastating
clinical presentation that requires emergent repair whenever possible. Contained rupture commonly
manifests as an aortic pseudoaneurysm, defined as a dilatation of the aorta due to disruption of all wall
layers, which is only contained by the periaortic connective tissue [17,80] .

The most common location of traumatic aortic injury is at the aortic isthmus just distal to the left
subclavian artery, followed by the supravalvular portion of the ascending aorta. This is a result of torsion
and shearing stress, while these structures are relativly immobile [18,62,80] . For TEE during surgery, it is
important to visualize the aorta as much as possible to rule out any undetected lesions. TAI is frequently
[80]
accompanied by mediastinal hematoma .

Aortic coarctation
Aortic coarctation is characterized as a narrowing of the aortic lumen due to a ridge of dense tissue. It is
most often located just distal to the left subclavian artery, where the former ductus arteriosus was
[81]
situated . Aortic coarctation is typically congenital, although it can have an acquired cause due to
[82]
inflammatory diseases or severe atherosclerosis . Severe stenosis is suggested by high-velocity flow on CFD
with continuous systolic and diastolic forward flow. Doppler gradient measurements are often unreliable
because of the inadequate alignment of the ultrasound beam [81,83] . Post-stenotic dilatation of the descending
aorta may be observed. Structural lesions associated with aortic coarctation and detectable with TEE are
bicuspid aortic valve, left heart inflow and outflow anomalies, ventricular septum defects, and patency of the
ductus arteriosus.

TEE can differentiate aortic coarctation from other aortic arch anomalies, such as pseudocoarctation and
aortic arch hypoplasia. In pseudocoarctation, a marked dilatation of the aorta and kinking of the proximal
descending aorta can be seen on ultrasound. Aortic arch hypoplasia, although rarely discovered in adults, is
[84]
characterized by incompletely developed, narrowed arch with acute angulation .

Infectious endocarditis
Infectious endocarditis (IE) is a severe disease affecting heart tissue and valves and is associated with high