Illustration of heart aorta with intramural hematoma.

TAVR Complications: How to Spot and Manage This Rare Aortic Injury

Elliot Brynn in Health & Wellness December 2025 • 4 min read.

"Aortic injury following Transcatheter Aortic Valve Replacement (TAVR) is rare but serious. Learn about a unique case and how a 'watch-and-wait' approach can be effective."

Transcatheter Aortic Valve Replacement (TAVR) has become a game-changer for individuals with severe aortic stenosis, offering a less invasive alternative to traditional surgery. While TAVR is generally safe, like all medical procedures, it carries potential risks. One such risk, though uncommon, is aortic injury.

Aortic injuries following TAVR can manifest in different ways, including aortic dissection or intramural hematoma (IMH). An intramural hematoma is characterized by bleeding within the wall of the aorta, the body's largest artery. Recognizing and managing these complications promptly and effectively is crucial for ensuring the best possible outcomes for patients.

This article delves into a fascinating case of a transient aortic intramural hematoma that occurred shortly after a TAVR procedure. We'll explore how doctors identified the issue, the treatment strategy they employed, and the remarkable recovery of the patient. This case highlights the importance of vigilance and tailored management approaches in the world of cardiac care.

Understanding Aortic Intramural Hematoma (IMH) After TAVR

Illustration of heart aorta with intramural hematoma.

In a medical study published in 'AORTA' December 2016, a case report detailed an 83-year-old woman with severe symptomatic aortic stenosis. She underwent TAVR due to her high surgical risk, indicated by a Society of Thoracic Surgeons score of 4.6 and a combined morbidity/mortality risk of 20.1%.

Following the procedure, an intraoperative transesophageal echocardiogram (TEE) revealed the development of an aortic intramural hematoma (IMH) with 9-10mm crescentic thickening of the wall. The IMH extended 2-3 cm above the valve. Interestingly, pre-operative imaging had shown no signs of this condition. Given the patient's stability, doctors opted for a conservative management approach involving blood pressure control and surveillance imaging.

Here's a quick recap of the patient's journey:

Initial Presentation: 83-year-old woman with severe aortic stenosis.
Procedure: Transcatheter Aortic Valve Replacement (TAVR).
Complication: Development of aortic intramural hematoma (IMH) detected post-TAVR.
Management: Conservative approach with blood pressure control and surveillance.
Outcome: Rapid resolution of IMH observed through follow-up imaging.

Subsequent TEE the following day revealed a significant reduction in the IMH, decreasing to a maximum wall thickness of 3-4 mm. Further imaging confirmed the stability and eventual complete resolution of the hematoma within two months. The patient remained stable 12 months after discharge, showcasing the effectiveness of the chosen treatment strategy.

The "Watch-and-Wait" Approach: Is It Right for Everyone?

The case highlights that while aortic injuries post-TAVR can be alarming, a conservative 'watch-and-wait' approach, coupled with blood pressure management and careful monitoring, can be a viable option in certain situations. This strategy is particularly relevant for elderly patients with specific criteria, like an aortic size less than 5 cm and IMH less than 11 mm. Of course, the optimal approach depends on individual patient factors, and surgical intervention remains the standard of care for acute aortic dissections post-TAVR in appropriate surgical candidates. If the dissection extends into the sinuses of Valsalva or if the coronary arteries are involved, then surgery is clearly indicated. Always consult your physician for medical advice.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.12945/j.aorta.2016.16.029, Alternate LINK

Title: Transient Aortic Intramural Hematoma Complicating Transaortic Valve Replacement

Subject: Cardiology and Cardiovascular Medicine

Journal: AORTA

Publisher: Georg Thieme Verlag KG

Authors: Taylor Thomas, Anil Poulose, Kevin Harris

Published: 2016-12-01

Everything You Need To Know

What is an aortic intramural hematoma (IMH) and how does it relate to Transcatheter Aortic Valve Replacement (TAVR)?

An aortic intramural hematoma (IMH) is characterized by bleeding within the wall of the aorta, the body's largest artery. It can occur as a rare complication following Transcatheter Aortic Valve Replacement (TAVR). In the context provided, it's important to understand that while TAVR is a less invasive procedure for aortic stenosis, it still carries risks, including aortic injury, such as IMH. This is a serious complication that requires careful management to ensure the best possible outcomes for patients.

What are the different ways aortic injuries can manifest after a TAVR procedure?

Aortic injuries following Transcatheter Aortic Valve Replacement (TAVR) can manifest in several ways, including aortic dissection or intramural hematoma (IMH). An aortic dissection involves a tear in the inner layer of the aorta, allowing blood to flow between the layers of the aortic wall. On the other hand, intramural hematoma (IMH) is characterized by bleeding within the wall of the aorta. Prompt recognition and management of these complications are crucial for patient well-being.

How was the aortic intramural hematoma (IMH) managed in the case of the 83-year-old woman post-TAVR?

In the specific case, the doctors opted for a conservative 'watch-and-wait' approach for the 83-year-old woman after the Transcatheter Aortic Valve Replacement (TAVR) procedure. This involved monitoring the patient and controlling her blood pressure. The IMH was initially detected through an intraoperative transesophageal echocardiogram (TEE). Subsequent imaging revealed that the IMH resolved within two months, demonstrating the effectiveness of this management strategy. The conservative approach was selected because the patient was stable.

What is the 'watch-and-wait' approach and when is it appropriate for treating aortic injuries after TAVR?

The 'watch-and-wait' approach is a conservative strategy used to manage aortic injuries, specifically aortic intramural hematoma (IMH), after Transcatheter Aortic Valve Replacement (TAVR). It involves careful monitoring of the patient with surveillance imaging and managing blood pressure. This approach is suitable in certain situations, especially for elderly patients meeting specific criteria. For example, the patient in the study had an aortic size less than 5 cm and IMH less than 11 mm. Surgical intervention remains the standard of care for acute aortic dissections post-TAVR in appropriate surgical candidates, particularly if the dissection extends into the sinuses of Valsalva or if the coronary arteries are involved.

What factors influenced the treatment strategy for the aortic intramural hematoma (IMH) in the provided case, and what were the outcomes?

The treatment strategy for the aortic intramural hematoma (IMH) in the case of the 83-year-old woman post-Transcatheter Aortic Valve Replacement (TAVR) was influenced by several factors. First, the patient's stability was a key determinant. Second, the initial imaging using an intraoperative transesophageal echocardiogram (TEE) revealed the presence of the IMH. The doctors opted for a conservative 'watch-and-wait' approach involving blood pressure control and surveillance imaging. The patient's Society of Thoracic Surgeons score of 4.6 and a combined morbidity/mortality risk of 20.1% also influenced the treatment. The outcome was positive: the IMH resolved within two months, and the patient remained stable 12 months after discharge. This outcome underscores the potential effectiveness of the 'watch-and-wait' approach in suitable cases.