Although the treatment of TAIMH were under consensus in different regions, surgery was advocated when TAIMH was accompanied by the PAU, which was a predictor of progress of the TAIMH [
3]. However, Lyons et al. summarized endovascular management of TAIMH With a distal primary entry tear and there were no in-hospital mortality and 2 died in the short-term follow-up of 24 months in the 17 patients [
4]. As for KD, aggressive treatment was proposed given the risk of rupture, but the operative mortality associated was high (16%) and the experience of endovascular exclusion was limited [
5]. With the development of imaging technologies, the small intimal tear or rupture of atherosclerotic plaque which was found in the ward and some of them were confirmed during the operation within some patients with IMH, which was different from the classical definition or ‘aortic dissection without intimal tear’ [
6‐
8]. Furthermore, Grimm et al. suggested the TAIMH could be induced by the atherosclerotic plaque rupture located in descending aorta, which was similar to our case [
9]. Therefore, based on the previous studies, we assumed that the patient could benefit from the excluded PAU by TEVAR along with the basic medical therapy and took the strategy of ‘wait and see’ for the KD, which actually slowed down the progression of aneurysms by controlling the blood pressure and heart rates. But he was thought to experience progress of the disease not too long after the intervention for the reason that no complications were observed at the end of the intervention, which might be also relevant with the unclear causes of the IMH or veiled tear which was undetected within the imaging technology at present besides the lesion secondary to TEVAR [
4]. The complexity of these entities should not be neglected whether treatment strategy was carried out. ARSA would increase the difficulty for total arch replacement and TAIMH with KD had a negtive impact on landing and release of the stent as well. For patients who had comorbidities and higher risks of surgery, TEVAR had less invasive incision and complications but required serious follow-up additionally. Although the patient survived over 5 years, the problem and challenge emerging after TEVAR suggested that it should be prudent to treat TAIMH accompanied with PAU by TEVAR, especially with other vascular malformations existing.
TEVAR with medical treatment may be a potential alternative approach for TAIMH accompanied by PAU located in descending aorta when surgery is unavailable and the researches of larger sample size and longer follow-up are required to verify the rationality of this strategy.