Midterm results of type B intramural hematoma endovascular treatment

Features and outcomes of focal intimal disruption in acute type B intramural haematoma

OBJECTIVES

A focal intimal disruption (FID) is a risk factor for adverse aorta-related events in patients with acute type B intramural haematoma. This study evaluated the impact of FIDs on overall survival with a selective intervention strategy for large or growing FIDs. Additionally, this study evaluated the risk factors associated with the growth of FIDs.

METHODS

This retrospective study included all consecutive patients admitted for acute type B intramural haematomas between November 2004 and April 2021. The primary outcome was overall survival. The secondary outcome was the cumulative incidence of composite aortic events and the growth of FIDs. The latter was calculated on centreline-reconstructed computed tomography images.

RESULTS

A total of 105 patients were included. A total of 106 FIDs were identified in 73 patients (73/105, 69.5%). The 1- and 5-year cumulative incidence rates of composite aortic events were 36.2% and 39.2%, respectively. The 1- and 5-year overall survival was 93.3% and 81.5%, respectively. Initial maximal aortic diameter and large FIDs during acute phase were significant risk factors for composite aortic events, but not risk factors for overall survival. The early appearance interval of an FID was a significant risk factor for growth of an FID.

CONCLUSIONS

With a selective intervention strategy for large or growing FIDs, the presence of large FIDs during the acute phase does not affect overall survival. The early appearance interval was associated with the growth of FIDs.

Clinical study of reoperation for acute type A aortic dissection

Objective

The initial operation for type A aortic dissection has limitations, and there may be a need for reoperation in cases such as giant pseudoaneurysm formation and reduced blood supply to the distal vessels. In this study, we collected case data of patients who underwent cardiac major vascular surgery at our hospital to analyze the effectiveness of reoperation treatment options for type A aortic dissection and to summarize our treatment experience.

Method

Between June 2018 and December 2022, 62 patients with type A aortic dissection (TAAD) underwent reoperation after previous surgical treatment. Of these, 49 patients (45 males) underwent endovascular aortic repair (EVAR) with a mean age of (49.69 ± 10.21) years (30-75 years), and 13 patients (11 males) underwent thoracoabdominal aortic replacement (TAAR) with a mean age of (41.00 ± 11.18) years (23-66 years). In this study, we retrospectively analyzed the recorded data of 62 patients. In addition, we summarized and analyzed their Computed Tomographic Angiography (CTA) results and perioperative complications.

Outcome

In the EVAR group, 47 patients (95.92%) were successfully implanted with overlapping stents, and 2 patients died in the perioperative period. Postoperative complications included cerebral infarction (4.08%), acute renal insufficiency (30.61%), pulmonary insufficiency and need for ventilator (6.12%), poor wound healing (2.04%), postoperative reoperation (16.33%), and lower limb ischemia (2.04%). In the TAAR group, 12 patients (92.31%) were successfully revascularized and 1 patient died in the perioperative period. Postoperative complications included cerebral infarction (7.69%), acute kidney injury (46.15%), pulmonary insufficiency and need for ventilator (15.38%), poor wound healing (30.77%) and postoperative reoperation (15.38%).

Conclusion

According to the results of the study, compared with TAAR, EVAR was less invasive, faster recovery, and offered a better choice for some high-risk and high-age patients with comorbid underlying diseases. However, the rate of revascularization was higher after EVAR than TAAR due to vascular lesions. Compared with the use of ascending aortic replacement + hemi-aortic arch replacement for acute type A aortic dissection in many countries and regions, the use of ascending aortic replacement + aortic arch replacement + elephant trunk stent is more traumatic in China, but facilitates reoperation. For young patients, the choice of treatment should be individualized combining vascular lesions and long-term quality of life.

Aortic injury caused by esophageal foreign body-case reports of 3 patients and literature review

OBJECTIVES

Ingestion of a foreign body can cause different degrees of damage to esophagus, and several complications are potentially life-threatening if not properly handled. The aortic injury caused by a perforating esophageal foreign body is rare but lethal. The optimal management still remains controversial. The purpose of this report is to describe our experience in the management of the aortic injury caused by esophageal foreign body ingestion.

METHODS

Between January 2015 and December 2015, we retrospectively enrolled cases of esophageal perforation involving the aorta by foreign body. The general parameters, esophageal foreign body, types of aortic injury, treatment, and outcome were analyzed. Additionally, we reviewed the literature of the management of esophageal perforation involving the aorta caused by foreign bodies. The study was approved by the ethics committee of the First Affiliated Hospital, College of Medicine, Zhejiang University, and the need for informed consent was waived (Quick review 2019, No. 609).

RESULTS

Three cases of esophageal perforation involving the aorta by foreign body was selected in the study. Two male and 1 female patients (range, 51-58 years old) with the aorta involvement caused by a perforating foreign body in the esophagus in 3 forms were identified, including 1 patient with mycotic aortic pseudoaneurysm, 1 patient with aortoesophageal fistula and 1 patient with the aortic intramural hematoma. One patient died of the rupture of the pseudoaneurysm during the preparation of the surgery. The other 2 patients were cured with a multidisciplinary approach, which is an urgent thoracic endovascular aortic repair followed by mediastinal debridement/drainage or endoscopic retrieval. Two of 3 patients were survived until now.

CONCLUSION

The management of the aortic injury caused by esophageal foreign body injury is challenging. Early diagnosis and multidisciplinary management is crucial.

Is the Natural Anatomical Evolution of Type B Intramural Hematomas Reliable to Identify the Patients at Risk of Aneurysmal Progression?

BACKGROUND

The natural history of type B intramural hematomas is little-known. Aneurysmal progression or an aortic dissection occurs in 15 to 20% of the cases. The study of the natural anatomical evolution could help identify the patients at risk of unfavorable evolution.

METHODS

All the patients monitored for a type B intramural hematoma between 2009 and 2018 were included in this monocentric retrospective study. Computed tomography angiography centerline measurement of diameters was obtained in various points of aortic segmentation on day (D) 0 and at one month (M1). Aortic volumes (lumen, intramural hematoma, and total volume) were calculated. The circulating volume was calculated using the volume rendering method. The volume of the intramural hematoma was measured using a manual section-by-section segmentation tool, and the total volume was obtained by summing up the two preceding volumes. Two groups of patients were compared: group 1 (favorable anatomical evolution) and group 2 (unfavorable anatomical evolution).

RESULTS

Between January 2008 and August 2018, 25 patients were managed for a type B intramural hematoma in our center. After an average follow-up of 15.5 months (1-52), 13 patients (52%) presented a favorable evolution and 12 (48%) an unfavorable evolution. At M1, a significant increase of the luminal diameters (37 mm vs. 32 mm; P < 0.01) and a significant reduction in the longitudinal extension (19 mm vs. 26 mm; P < 0.01) were observed. The maximum aortic diameter evolved significantly between D0 and M1 in the unfavorable evolution group (49 mm vs. 44 mm, respectively; P = 0.038). Such a difference was not found in the favorable evolution group (37.4 vs. 37.1, respectively; P = 0.552). An overall significant reduction in the total aortic volume (166 cm³ vs. 219 cm³; P < 0.01), the circulating volume (124 cm³ vs. 145 cm³; P = 0,026), and the volume of the hematoma (42 cm³ vs. 39 cm³; P < 0.01) was observed. The circulating volume decreased significantly between D0 and M1 in the favorable evolution group (110 cm³ vs. 135 cm³; P = 0.05), whereas no difference was noted in the unfavorable group (142 cm³ vs, 157 cm³; P = 0.24).

CONCLUSIONS

The progression of the maximum aortic diameter and of the circulating volume after one month of follow-up could be predictive factors of the poor long-term evolution of type B intramural hematomas.

Endovascular versus medical management of type B intramural hematoma: a meta-analysis

Background

Aortic intramural hematoma constitutes one of the three classifications of acute aortic syndrome (AAS). Type B intramural hematoma (IMH-B) is localized to the descending thoracic aorta and can be managed through medical, endovascular or surgical means. Data comparing contemporary management with thoracic endovascular aortic repair (TEVAR) versus traditional medical management (MM) is sparse and only moderate strength recommendations for TEVAR are provided in guidelines. This meta-analysis aimed to pool available data from comparative studies between TEVAR and MM and examine differences in outcomes.

Methods

Literature search of electronic medical databases was conducted to identify studies comparing TEVAR and MM for management of IMH-B. Data extraction from studies fulfilling the inclusion criteria was performed by two authors and meta-analysis using a random-effects model applied to pool baseline data and examine risk ratios (RR) for management outcomes.

Results

Of the initial 2,349 studies, nine studies were identified for analysis. There were 161 TEVAR patients and 166 who were medically managed. The mean age of the cohort was 62.2 years [95% confidence interval (CI): 55.8-68.7 years]. Patients with complicating features of IMH-B at presentation were more likely to appear in the TEVAR group, with more penetrating atheromatous ulcer (PAU) [risk difference (RD), 0.565, 95% CI: 0.240-0.889, P=0.001], ulcer-like projection (ULP) (RD 0.240, 95% CI: 0.965-0.384, P=0.001), and greater IMH size (mean difference, MD 5.47 mm, 95% CI: 0.320-10.6, P=0.037). There was no statistical difference between TEVAR and MM for the primary endpoints of aortic-related death (RR 0.535, 95% CI: 0.191-1.5, P=0.234) or IMH-B regression (RR 1.25, 95% CI: 0.859-1.81, P=0.246). Of the secondary endpoints, TEVAR had both significantly less dissection during follow-up (RR 0.295, 95% CI: 0.0881-0.989, P=0.048) and less rupture during follow-up (RR 0.206, 95% CI: 0.0462-0.921, P=0.039).

Conclusions

A small number of series comparing TEVAR and MM for management of IMH-B are available and random-effects meta-analysis did not reveal any statistically significant difference between treatments for aortic related death or IMH-B regression at a mean follow-up of 37 months. TEVAR was found to be associated with lower risk of dissection and lower risk of rupture during follow-up. Baseline data meta-analysis showed patients with complicating features of PAU, ULP, and larger IMH size were more likely to be managed with TEVAR.

Aortic intramural hemorrhage: A distinct disease entity with mystery

Aortic intramural hemorrhage (IMH) is one of the disease processes that comprise the spectrum of acute aortic syndrome (AAS) with clinical manifestations and a mortality rate similar to those of classic aortic dissection (AD). However, IMH should be considered as a distinct disease entity rather than a precursor to classic dissection because of differences in their pathology, etiology, natural history, and imaging findings. Multidetector computed tomography (CT) is recommended as the first-line diagnostic imaging modality for IMH, but transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are also helpful. There is still debate over the appropriate treatment of IMH. Medical treatment of type B IMH appears effective and safe, while surgical treatment is recommended for type A IMH. Thoracic endovascular aortic repair (TEVAR) is a promising treatment for selected patients, and more clinical evidence needs to be assembled.