1
|
Kageyama S, Ohashi T, Yoshida T, Kobayashi Y, Kojima A, Kobayashi D, Kojima T. Early mortality of emergency surgery for acute type A aortic dissection in octogenarians and nonagenarians: A multi-center retrospective study. J Thorac Cardiovasc Surg 2024; 167:65-75.e8. [PMID: 35277246 DOI: 10.1016/j.jtcvs.2022.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The clinical data on postoperative mortality and central nervous system (CNS) complications in older adults who underwent acute type A aortic dissection are limited. Thus, in this study we aimed to evaluate the association between age and early postoperative mortality and occurrence of CNS complications. METHODS This multicentric retrospective cohort study included 5 tertiary hospitals in Japan. All patients who underwent emergency surgery for acute type A aortic dissection between October 1998 and December 2019 were enrolled. The multilevel Cox proportional hazards model, which considered years as level 1, institutions as level 2, and surgeons as level 3, was used to evaluate the association between age and early postoperative hospital mortality and occurrence of CNS complications. RESULTS Of the 1037 patients, 227 (21.9%) were ≥80 years old and 810 (78.1%) were <80 years old. Overall, 134 patients (12.9%) died within 30 days postoperatively; among them, 42/227 (18.5%) and 92/810 (11.4%) were aged ≥80 and <80 years, respectively (hazard ratio [HR], 1.63; P = .0046). CNS complications within 30 days postoperatively occurred in 140/1037 (13.5%) patients; among them, 42/227 (18.5%) and 98/810 (12.1%) were aged ≥80 and <80 years, respectively (HR, 1.63; P = .011). In multivariate analysis, age ≥80 years was associated with mortality within 30 days postoperatively (adjusted HR, 2.37; 95% CI, 1.23-4.57; P = .01) but not with CNS complications (adjusted HR, 1.58; 95% CI, 0.93-2.69; P = .091). CONCLUSIONS The early postoperative mortality in older patients was approximately 50% higher than in the younger population. A thorough discussion regarding the surgical indications should be done.
Collapse
Affiliation(s)
- Soichiro Kageyama
- Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital, Kasugai-city, Aichi, Japan
| | - Takeki Ohashi
- Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital, Kasugai-city, Aichi, Japan
| | - Takeshi Yoshida
- Department of Cardiovascular Surgery, Matsubara Tokushukai Hospital, Matsubara-city, Osaka, Japan
| | - Yutaka Kobayashi
- Department of Cardiovascular Surgery, Uji Tokushukai Hospital, Makishima-cho, Uji-city, Kyoto, Japan
| | - Akinori Kojima
- Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital, Kasugai-city, Aichi, Japan
| | - Daiki Kobayashi
- Graduate School of Public Health, St Luke's International University, Tokyo, Japan
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu-shi, Aichi, Japan.
| |
Collapse
|
2
|
Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | | |
Collapse
|
3
|
Yang KJ, Chi NH, Yu HY, Chen YS, Wang SS, Wu IH. Outcome Comparison Between Open and Endovascular Aortic Repair for Retrograde Type A Intramural Hematoma With Intimal Tear in the Descending Thoracic Aorta: A Retrospective Observational Study. Front Cardiovasc Med 2021; 8:755214. [PMID: 34733898 PMCID: PMC8558361 DOI: 10.3389/fcvm.2021.755214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/22/2021] [Indexed: 01/16/2023] Open
Abstract
Objective: The optimal treatment modality for retrograde type A intramural hematoma (IMH) remains debatable. This study evaluated and compared surgical outcomes and aortic remodeling after open aortic repair and thoracic endovascular aortic repair (TEVAR) in patients with retrograde type A IMH with a primary intimal tear or ulcer like projection in the descending aorta. Methods: A single center, retrospective observational study was performed on patients with retrograde type A IMH undergoing either open aortic repair and TEVAR. From June 2009 and November 2019, 46 patients with retrograde type A IMH who received either open aortic repair or TEVAR at our institution were reviewed for clinical outcomes, including post-operative mortality/morbidity, re-intervention rate and aortic remodeling. Results: 33 patients underwent open aortic repair and 13 underwent TEVAR. Median age was 68 years (interquartile range [IQR] 15.2 years) and 63 years (IQR 22.5 years) for the open repair group and TEVAR group, respectively. The median duration of follow-up for TEVAR patients was 37.6 months and 40.3 months for open aortic repair. No difference in the 5-year estimated freedom from all-cause mortality (82.1 vs. 87.8%, p = 0.34), re-intervention (82.5 vs. 93.8%, p = 0.08), and aortic-related mortality (88.9 vs. 90.9%, p = 0.88) were observed between the TEVAR and open repair group, respectively; however, the open repair group had a significantly higher 30-day composite morbidity (39.4 vs. 7.7%, p = 0.037). All patients from both treatment groups had complete resolution of the IMH in the ascending aorta. With regard to the descending thoracic aorta, TEVAR group had a significantly greater regression in the diameter of the false lumen or IMH thickness when compared to the open repair group [median 14mm (IQR 10.1) vs. 5mm (IQR 9.5), p < 0.001]. Conclusion: TEVAR and open aortic repair were both effective treatments for retrograde type A IMH, in which no residual ascending aortic IMH was observed during follow-up. TEVAR was also associated with lower post-operative composite morbidities and better descending aortic remodeling. In selected patients with retrograde type A IMH, TEVAR might be a safe, effective alternative treatment modality.
Collapse
Affiliation(s)
- Kelvin Jeason Yang
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nai-Hsin Chi
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsi-Yu Yu
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yih-Sharng Chen
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shoei-Shen Wang
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, Fu Jen Catholic University Hospital, Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan
| | - I-Hui Wu
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
4
|
Martín-Gutiérrez E, Gualis-Cardona J, Maiorano P, Castillo-Pardo L, Laguna-Núñez G, Castaño-Ruiz M. Tratamiento conservador vs. quirúrgico en el hematoma intramural agudo tipo A: revisión bibliográfica, metaanálisis y análisis de diferencias temporales y geográficas. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
5
|
Stepwise external wrapping procedure for type A intramural hematoma. J Thorac Cardiovasc Surg 2020; 164:31-38.e1. [DOI: 10.1016/j.jtcvs.2020.08.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/21/2020] [Accepted: 08/06/2020] [Indexed: 11/21/2022]
|
6
|
Shi Y, Dun Y, Guo H, Liu Y, Zhang B, Qian X, Yu C, Sun X. Clinical features and surgical outcomes of type A intramural hematoma. J Thorac Dis 2020; 12:3964-3975. [PMID: 32944308 PMCID: PMC7475568 DOI: 10.21037/jtd-20-748] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Data on the clinical features and surgical outcomes of type A intramural hematoma (IMH) in Chinese patients are very limited. We aimed to present the surgical experiences on type A IMH in our center, and report early and late outcomes. Methods From February 2012 to April 2018, 106 consecutive patients underwent open surgery for type A IMH at our hospital. We adopted emergent operation for patients with cardiac tamponade or other severe complications, and recommended initial medical treatment followed by elective surgery for stable patients. The composite endpoints included operative mortality, permanent nerve damage (stroke, paraplegia), and new-onset renal failure necessitating hemodialysis. Risk factors for operative mortality and the composite endpoints were identified using univariable and multivariable logistic regression model analysis. The survival and freedom from aortic events were analyzed using a Kaplan-Meier surviving curve and a log-rank test. Results Except 1 patient receiving emergent surgery (within 24 hours from onset) because of cardiac tamponade and cerebral malperfusion, all patients received initial medical treatment and delayed surgery. Two patient developed pericardial tamponade while waiting for surgery, and then received emergent surgery. Preoperative conversion to aortic dissection (AD) was noted in no patient. The operative techniques included ascending aorta replacement in 9 patients, hemiarch replacement in 18 patients, total arch replacement (TAR) with frozen elephant trunk (FET) in 45 patient and hybrid aortic arch repair in 34 patients. The mean cardiopulmonary bypass (CPB) time and cross-clamp time were 138.7±41.6 and 79.3±27.8 min, respectively. The operative mortality was 1.9% (2/106). And the composite endpoints occurred in 7 patients. Multivariable logistic regression analysis showed CPB time ≥200 min and chronic kidney disease were risk factors for the composite endpoints. The follow-up data were available in 97 survivors, with the mean follow-up time of 30.8±16.2 months. Three patients died and 5 patients developed aortic events during the follow-up. The overall survival at 1-, 3- and 5-year were 97.0%, 95.3%, and 79.4%, respectively. And freedom from aortic events at 1-, 3- and 5-year were 97.7%, 95.3% and 89.4%, respectively. Conclusions Our strategy had got low mortality and excellent mid-term survival in patients with type A IMH. Therefore, our strategy was suitable for the surgical repair of type A IMH in Chinese population.
Collapse
Affiliation(s)
- Yi Shi
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaojun Dun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanxiang Liu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bowen Zhang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
7
|
Li YL, Ye JC, Yancu H, Liu B, Wang YZ, Wang WJ, Wang W, Li D, Chang HY. Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Associated with Retrograde Type A Intramural Hematoma. J Vasc Interv Radiol 2020; 31:1334-1341. [PMID: 32127315 DOI: 10.1016/j.jvir.2020.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/03/2020] [Accepted: 01/20/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate feasibility and efficacy of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) associated with retrograde type A intramural hematoma (IMH). MATERIALS AND METHODS From April 2013 to January 2017, 15 consecutive patients with TBAD associated with retrograde type A IMH who underwent TEVAR were reviewed retrospectively. There was no cardiac tamponade, aortic regurgitation, involvement of coronary artery, or sign of cerebral ischemia in these patients. Enhanced CT was used in 4 patients to diagnose malperfusion of abdominal visceral arteries or lower extremity artery and underwent emergent TEVAR. For the remaining 11 patients, repeated enhanced CT after initial medical treatment within 24 hours from onset of pain showed expansion of IMH in 8 patients or presence of periaortic hematoma in 3 patients. Delayed TEVAR was scheduled for these cases. RESULTS Successful deployment of the stent graft was achieved in all patients. There were no severe postoperative complications, such as retrograde type A aortic dissection or aortic rupture. Sudden death occurred in 1 patient 3 months after the procedure. Thrombosis of the false lumen, shrinkage of the diameter of the aorta, and complete absorption of the IMH were observed in the remaining patients at a mean follow-up of 19.8 months ± 6.57. CONCLUSIONS TEVAR for treatment of TBAD with retrograde type A IMH is feasible and effective. It represents a treatment option for patients with TBAD associated with type A IMH with a proximal entry tear located in the descending aorta.
Collapse
Affiliation(s)
- Yu-Liang Li
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Jia-Cheng Ye
- Department of Intervention Medicine, the First Hospital of Nanping Affiliated to Fujian Medical University, Nanping, Fujian, China
| | - Hertzanu Yancu
- Department of Radiology, Ben Gurion University of the Negev, Beersheba, Israel
| | - Bin Liu
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Yong-Zheng Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Wu-Jie Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Wei Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Dong Li
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Hai-Yang Chang
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China.
| |
Collapse
|
8
|
Chen YY, Yen HT, Lo CM, Wu CC, Huang DKR, Sheu JJ. Natural courses and long-term results of type A acute aortic intramural haematoma and retrograde thrombosed type A acute aortic dissection: a single-centre experience. Interact Cardiovasc Thorac Surg 2020; 30:113-120. [PMID: 31518390 DOI: 10.1093/icvts/ivz222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/09/2019] [Accepted: 08/16/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Few reports on the outcomes of patients treated for Stanford type A acute aortic intramural haematoma (TAAIMH) and retrograde thrombosed type A acute aortic dissection exist. This study aimed to evaluate their long-term results and predictors of adverse outcomes. METHODS We retrospectively analysed 40 patients with TAAIMH and retrograde thrombosed type A acute aortic dissection. All patients underwent urgent surgery on presentation of life-threatening complications. Before discharge, 18 patients underwent open aortic surgery, and 22 were treated with medical therapy alone. Clinical features of these patients and image appearances were reviewed, and the relationship with overall survival, aortic events, and aortic death was investigated. RESULTS The in-hospital mortality rate was 4.5% (1 patient) with medical therapy alone and 11.1% (2 patients) with surgical intervention. No patient with initial medical therapy required urgent surgery for life-threatening complications beyond 3 days of admission. The overall survival and aortic death-free survival rates at 1, 5 and 10 years were 85.0%, 72.5% and 59.8% and 90.0%, 81.6% and 77.1%, respectively. TAAIMH associated with penetrating aortic ulcer (PAU) was a risk factor of aortic events (P = 0.020) and significantly influenced aortic death-free survival (P = 0.003). CONCLUSIONS Urgent surgery for complicated TAAIMH and retrograde thrombosed type A acute aortic dissection patients and initial medical therapy for uncomplicated patients show favourable long-term survival rates. TAAIMH is frequently associated with PAU; PAU enlargement is common. Although PAU can remain stable for years, it is a strong predictor of poor prognosis. For optimal long-term results, surgical repair is recommended for TAAIMH associated with PAU.
Collapse
Affiliation(s)
- Yen-Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsu-Ting Yen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ming Lo
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Chen Wu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - David Kwan-Ru Huang
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jiunn-Jye Sheu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| |
Collapse
|
9
|
Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single-Center Experience. Ann Vasc Surg 2019; 65:224-231. [PMID: 31743779 DOI: 10.1016/j.avsg.2019.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/10/2019] [Accepted: 11/11/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The aim of this study is to present our experience of thoracic endovascular aortic repair (TEVAR) for type A intramural hematoma (TAIMH) and retrograde thrombosed type A aortic dissection (rt-TAAD) with the entry tear in the descending aorta or the abdominal aorta and discuss the outcomes. METHODS We retrospectively reviewed total 6 patients who underwent TEVAR for TAIMH (n = 2) or rt-TAAD (n = 4) in our hospital between September 2017 and July 2019. The mean age of the patients (5 men and 1 woman) was 74 ± 13 years, and the mean follow-up duration was 13 ± 7 months. RESULTS TEVAR was successfully performed in the acute phase in all patients without relevant complications. After TEVAR, the shrinkage of enlarged thoracic aorta and complete resorptions of the false lumen of the entire thoracic aorta were achieved in 4 patients. In the remaining 2 patients, one had residual thrombosed false lumen of the ascending aorta due to a new development of PAU at the distal aortic arch and another needed additional endovascular intervention for ascending aorta hematoma progression. Late aorta-related adverse event was observed in one patient, who needed open aortic repair. There was no death during follow-up. CONCLUSIONS Tear-oriented endovascular aortic repair is a potential option in selected patients of TAIMH and rt-TAAD and has shown favorable immediate outcomes and aortic remodeling. However, the late aorta-related adverse event is not negligible, and their long-term outcome has not been fully clarified. More research is warranted.
Collapse
|
10
|
Li JD, Ma WG, Sun LZ. Conservative arch management versus aggressive arch reconstruction for type A intramural hematoma. Ann Cardiothorac Surg 2019; 8:551-555. [PMID: 31667152 DOI: 10.21037/acs.2019.07.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jin-Dong Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| |
Collapse
|
11
|
Okita Y. Surgery for acute proximal non-communicating aortic dissection without intimal tears (intramural hematoma). Ann Cardiothorac Surg 2019; 8:570-573. [PMID: 31667157 DOI: 10.21037/acs.2019.08.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yutaka Okita
- Takatsuki General Hospital, Kobe University, Chuo-ku, Kobe, Japan
| |
Collapse
|
12
|
Okita Y. Current surgical results of acute type A aortic dissection in Japan. Ann Cardiothorac Surg 2016; 5:368-76. [PMID: 27563550 PMCID: PMC4973134 DOI: 10.21037/acs.2016.06.02] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/10/2016] [Indexed: 11/06/2022]
Abstract
Current surgical results of acute type A aortic dissection in Japan are presented. According to the annual survey by the Japanese Association of Thoracic Surgery, 4,444 patients with acute type A aortic dissection underwent surgical procedures and the overall hospital mortality was 9.1% in 2013. The prevalence of aortic root replacement with a valve sparing technique, total arch replacement (TAR), and frozen stent graft are presented and strategies for thrombosed dissection or organ malperfusion syndrome secondary to acute aortic dissection are discussed.
Collapse
Affiliation(s)
- Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| |
Collapse
|
13
|
Chou AS, Ziganshin BA, Charilaou P, Tranquilli M, Rizzo JA, Elefteriades JA. Long-term behavior of aortic intramural hematomas and penetrating ulcers. J Thorac Cardiovasc Surg 2016; 151:361-72, 373.e1. [DOI: 10.1016/j.jtcvs.2015.09.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/22/2015] [Accepted: 09/03/2015] [Indexed: 11/25/2022]
|
14
|
Matsushita A, Fukui T, Tabata M, Sato Y, Takanashi S. Preoperative characteristics and surgical outcomes of acute intramural hematoma involving the ascending aorta: A propensity score-matched analysis. J Thorac Cardiovasc Surg 2015; 151:351-8. [PMID: 26470908 DOI: 10.1016/j.jtcvs.2015.09.055] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 09/07/2015] [Accepted: 09/10/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We aimed to evaluate the preoperative characteristics and surgical outcomes of acute type A intramural hematoma. METHODS Between January 2000 and June 2011, 460 consecutive patients underwent emergency open surgery for type A acute aortic syndrome at Sakakibara Heart Institute. Among these patients, 121 had intramural hematoma and 339 had typical aortic dissection. We compared the clinical characteristics and surgical outcomes using propensity score matching. RESULTS In all patients, the intramural hematoma group had an older age (69.2 ± 10.4 years vs 63.4 ± 13.5 years; P < .001), included a higher ratio of female patients (56.2% vs 44.0%, P = .020), and more frequently had hypertension (94.2% vs 83.5%, P = .005), hyperlipidemia (25.6% vs 12.7%, P < .001), and cardiac tamponade (33.1% vs 18.3%, P < .001) than patients with aortic dissection. Cerebral malperfusion (0.8% vs 5.3%, P = .033), myocardial malperfusion (0.8% vs 8.2%, P = .002), lower limb malperfusion (1.7% vs 7.9%, P = .015), Marfan syndrome (0% vs 3.5%, P = .042), and aortic valve insufficiency (2.5% vs 15.0%, P < .001) were less frequently observed in the intramural hematoma group than in the aortic dissection group. After propensity score matching, 116 matched pairs were created. In the matched analysis, operative mortality was 0.9% in the intramural hematoma group (1/116) and 3.4% in the aortic dissection group (4/116, P = .179). The intramural hematoma group demonstrated higher actuarial 1- and 5-year survivals than the aortic dissection group (99.1 % vs 93.6% and 97.3% vs 85.9%, respectively, P = .006). In the multivariate analysis, intramural hematoma was shown to be associated with lower midterm mortality (hazard ratio, 0.316; 95% confidence interval, 0.102-0.974; P = .045). CONCLUSIONS Patients with intramural hematoma have different preoperative clinical characteristics compared with patients with aortic dissection. Emergency open surgery for type A intramural hematoma demonstrated low operative mortality and excellent 5-year survival.
Collapse
Affiliation(s)
- Akihito Matsushita
- Department of Cardiovascular Surgery, Chiba Medical Center, Chiba, Japan; Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan.
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Yasunori Sato
- The Clinical Research Center, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| |
Collapse
|
15
|
Matsushita A, Tabata M, Fukui T, Sato Y, Matsuyama S, Shimokawa T, Takanashi S. Outcomes of contemporary emergency open surgery for type A acute aortic dissection in elderly patients. J Thorac Cardiovasc Surg 2014; 147:290-4. [DOI: 10.1016/j.jtcvs.2012.11.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 10/03/2012] [Accepted: 11/06/2012] [Indexed: 11/24/2022]
|
16
|
Lansman SL, Saunders PC, Malekan R, Spielvogel D. Acute aortic syndrome. J Thorac Cardiovasc Surg 2010; 140:S92-7; discussion S142-S146. [DOI: 10.1016/j.jtcvs.2010.07.062] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 07/20/2010] [Accepted: 07/26/2010] [Indexed: 11/25/2022]
|
17
|
Sawaki S, Hirate Y, Ashida S, Takanohashi A, Yagami K, Usui M. Clinical Outcomes of Medical Treatment of Acute Type A Intramural Hematoma. Asian Cardiovasc Thorac Ann 2010; 18:354-9. [DOI: 10.1177/0218492310375855] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A retrospective study was performed in 30 patients who were treated for type A intramural hematoma from 1999 to 2008, of whom 24 were initially treated without surgical intervention. These 24 patients were followed up for 3.3 ± 3.5 years (range, 0 days to 10.0 years). Four hospital deaths occurred (hospital mortality, 16.7%), there were 2 late deaths, and 2 other patients needed an operation during the follow-up period. The event-free survival rate (freedom from death or surgery) at 5 years was significantly lower in patients with maximal aortic diameter ≤48 mm than in those with diameters <48 mm (28.6% ± 17.1% vs. 88.2% ± 7.8%). Maximal aortic diameter ≤48 mm and computed tomography findings of a small intimal defect were significant predictors of rupture or progression of ascending aortic dissection. The outcome of medical treatment for type A intramural hematoma was acceptable during both the early and late periods, but patients with a relatively large aortic diameter or an intimal defect in the ascending aorta have a high probability of adverse outcome, and must be considered for surgery.
Collapse
Affiliation(s)
- Sadanari Sawaki
- Department of Cardiovascular Surgery Nagoya Ekisaikai Hospital Aichi, Japan
| | - Yuichi Hirate
- Department of Cardiovascular Surgery Nagoya Ekisaikai Hospital Aichi, Japan
| | - Shinichi Ashida
- Department of Cardiovascular Surgery Nagoya Ekisaikai Hospital Aichi, Japan
| | - Akira Takanohashi
- Department of Cardiovascular Surgery Nagoya Ekisaikai Hospital Aichi, Japan
| | - Kei Yagami
- Department of Cardiovascular Surgery Nagoya Ekisaikai Hospital Aichi, Japan
| | - Masato Usui
- Department of Cardiovascular Surgery Nagoya Ekisaikai Hospital Aichi, Japan
| |
Collapse
|
18
|
Song JK, Yim JH, Ahn JM, Kim DH, Kang JW, Lee TY, Song JM, Choo SJ, Kang DH, Chung CH, Lee JW, Lim TH. Outcomes of patients with acute type a aortic intramural hematoma. Circulation 2009; 120:2046-52. [PMID: 19901188 DOI: 10.1161/circulationaha.109.879783] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The proper treatment option for patients with type A intramural hematoma (IMH), a variant form of classic aortic dissection (AD), remains controversial. We assessed the outcome of our institutional policy of urgent surgery for unstable patients and initial medical treatment for stable patients with surgery in cases with complications. METHODS AND RESULTS Among 357 consecutive patients with type A acute aortic syndrome, 101 (28.3%) had IMH and 256 had AD. Urgent operations were performed in 224 patients with AD (87.5%) and 16 with unstable IMH (15.8%; P<0.001). The remaining 85 stable IMH patients received initial medical treatment, and adverse clinical events developed in 31 patients (36.5%) within 6 months, which included development of AD (n=25), delayed surgery (n=25), or death (n=6). Initial aorta diameter and hematoma thickness were independent predictors for development of these events, and the best cutoff values were 55 and 16 mm, respectively. The overall hospital mortality was lower in IMH patients than in AD patients (7.9% [8/101] versus 17.2% [44/256]; P=0.0296) and was comparable to that of surgically treated AD patients (7.9% versus 10.7% [24/224]; P=0.56). The 1-, 2-, and 3-year survival rates of IMH patients were 87.6+/-3.6%, 84.9+/-3.7%, and 83.1+/-4.1%, respectively. There was no statistical difference of overall survival rates between patients with IMH and surgically treated AD patients (P=0.787). CONCLUSIONS The clinical outcome of IMH patients receiving treatment by our policy was comparable to that of surgically treated AD patients. However, adverse clinical events were not uncommon with medical treatment alone, and initial aorta diameter and hematoma thickness may identify patients who might benefit from urgent surgery.
Collapse
Affiliation(s)
- Jae-Kwan Song
- Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong Songpa-gu, Seoul, 138-736 South Korea.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Buckley O, Rybicki FJ, Gerson DS, Huether C, Prior RF, Powers SL, Ersoy H. Imaging features of intramural hematoma of the aorta. Int J Cardiovasc Imaging 2009; 26:65-76. [PMID: 19777368 DOI: 10.1007/s10554-009-9504-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Accepted: 08/28/2009] [Indexed: 11/28/2022]
Abstract
Intramural hematoma (IMH) is defined as localized hemorrhage within the aortic wall and is included in the acute aortic syndrome spectrum with aortic dissection and penetrating aortic ulcer. The mortality from IMH is similar to classic aortic dissection (21%). 16% of patients with IMH will evolve to classic aortic dissection over time. Despite this confusion exists regarding the precise definitions and radiologic features of IMH versus penetrating ulcers with mural thrombus and overt aortic dissection.
Collapse
Affiliation(s)
- Orla Buckley
- Noninvasive Cardiovascular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.
| | | | | | | | | | | | | |
Collapse
|
20
|
Kitai T, Kaji S, Yamamuro A, Tani T, Tamita K, Kinoshita M, Ehara N, Kobori A, Nasu M, Okada Y, Furukawa Y. Clinical Outcomes of Medical Therapy and Timely Operation in Initially Diagnosed Type A Aortic Intramural Hematoma: A 20-Year Experience. Circulation 2009; 120:S292-8. [DOI: 10.1161/circulationaha.108.843615] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
21
|
Chao CP, Walker TG, Kalva SP. Natural history and CT appearances of aortic intramural hematoma. Radiographics 2009; 29:791-804. [PMID: 19448116 DOI: 10.1148/rg.293085122] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Rupture of the vasa vasorum into the media of the aortic wall results in an aortic intramural hematoma. Characteristic findings of an aortic intramural hematoma include a crescentic hyperattenuating fluid collection at unenhanced computed tomography (CT) and a smooth, nonenhancing, thickened aortic wall at contrast material-enhanced CT. The CT appearance of untreated intramural hematomas evolves over time, and decreased attenuation is a clue to the chronicity of a hematoma. CT is particularly useful for evaluating aortic intramural hematomas because it allows their differentiation from aortic dissections, which have similar clinical manifestations, and permits an exact determination of their location-crucial information for surgical planning. On the basis of CT findings, some hematomas may be expected to resolve spontaneously, whereas others may be identified as posing a high risk for serious complications such as aortic dissection, aneurysm, and rupture. Appropriate clinical management is aided by accurate recognition of diagnostically specific CT features and awareness of their significance.
Collapse
Affiliation(s)
- Christine P Chao
- Department of Radiology, Massachusetts General Hospital, Boston, Mass., USA.
| | | | | |
Collapse
|