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Background: Prognostic value of new development of Ulcer-like projection (ULP) in type B aortic intramural hematoma (IMH) remains unclear. For this reason, the best treatment for these patients is not well-defined.Objectives: To assess long term outcome of patients with type B IMH with ULP and to define morphological and clinical predictors of complication.Methods: 44 consecutive patients with acute type B IMH with new ULP were followed by a prospective clinical and imaging protocol. The mean follow-up was 8.6±4.2 years. Surgical treatment or endovascular therapy was indicated in patients with impending signs of aortic rupture, maximum aortic diameter (MAD) ≥60mm or rapid enlargement of ULP (>3mm/year).Results: Only 4 patients (9%) died, but due to non-aortic causes. 7 (16%) patients met with criteria of surgical treatment: 3 (7%) underwent endovascular therapy (2 patients due to enlargement of MAD and 1 due to rapid ULP enlargement) and 4 (9%) were rejected due to comorbidities, but they remained alive during the follow-up. 51 ULP were detected, being the mean depth 12.7±7.0mm (range 3-31mm). During follow-up: 11 ULP (22%) presented reduction in the depth (4 -8%- of them disappeared), 11 (22%) remained stable and 29 (56%) enlarged. Changes of ULP and MAD size (mm/year) correlated significantly r=0.53 (p<0.001). Basal ULP depth showed a good diagnosis accuracy to detect patients who will present surgical indication (area under the curve=86.3%, p=0.001). A basal ULP depth ≥ 13mm showed a sensitivity of 88% and a specificity of 65% for surgical treatment indication during follow-up.Conclusions: New development of ULP is not a fatal sign in type B IMH and can be managed with medical treatment in most cases. Initial ULP depth predicts patients who presented criteria for surgical intervention during follow-up.