Aortic intramural hematoma is a contained aortic wall hematoma without a demonstrable intimal flap. It is similar to aortic dissection, but the pathology and pathophysiology are different. We report a patient with a chronic descending thoracic aortic intramural hematoma presenting with acute rupture and periaortic hematoma along with concomitant acute ST-elevation myocardial infarction that proved to be catastrophic without intervention. We discuss the diagnostic and therapeutic dilemma.
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