Computed tomography evaluation of aortic remodeling after endovascular treatment for complicated ulcer-like projection in patients with type B aortic intramural hematoma

Natural history and long-term outcomes of medically managed Type B intramural hematoma

OBJECTIVE

Type B intramural hematoma (IMH) is often managed medically, yet may progress to dissection, aneurysmal dilation, or rupture. The aim of this study was to report the natural history of medically managed Type B IMH, and factors associated with progression.

METHODS

We reviewed patients with medically managed Type B IMH between January 1995 to December 2022 at a single center. Any patients with immediate surgical or endovascular intervention were excluded. Demographic profiles, comorbidities, imaging, and follow-up details were reviewed. Patients were divided into two groups: Group 1 had isolated IMH, and Group 2 had IMH along with aneurysm or dissection at the time of presentation. On follow-up, progression was defined as degeneration to aneurysm/dissection or increase in the thickness of IMH in Group 1. In Group 2, progression was an increase in the size of aneurysm or development of new dissection.

RESULTS

Of 104 patients with Type B IMH during the study period, 92 were medically managed. The median age was 77 years, and 45 (48.9%) were females. Comorbidities included hypertension (83.7%), hypercholesterolemia (44.6%), and active smoking (47.8%). Mean Society for Vascular Surger comorbidity score was 6.3. Mean IMH thickness and aortic diameter at presentation were 8.9 mm and 38.3 mm, respectively. Median follow-up was 55 months. Overall survival at 1 year and 5 years was 85.8% and 61.9%, respectively. During follow-up, 19 patients (20.7%) required intervention, more common in Group 2 (Group 1, 8/66; 12.3% vs Group 2, 11/26; 42.3%; P = .001). This resulted in higher freedom from intervention in Group 1 at 1 year (93.5% vs 62.7%) and 5 years (87.5% vs 51.1%; P < .001). Indication for intervention was dissection (n = 4), aneurysm (n = 12), and progression of IMH (n = 3). In Group 1, progression was seen in 25 (37.9%), three (4.5%) remained stable, 29 (43.9%) had complete resolution of IMH, and nine patients were lost to follow-up. In Group 2, 11 patients (42.3%) had progression, seven (26.9%) remained stable, and eight were lost to follow-up. IMH thickness at presentation >7.2 mm is associated with both increased odds of progression (odds ratio, 3.3; 95% confidence interval, 1.2-11.1; P = .03) and intervention (odds ratio, 5.5; 95% confidence interval, 1.3-36.9; P = .03) during the follow-up.

CONCLUSIONS

Although many patients with Type B IMH managed medically stabilize or regress, progression or need for intervention can occur in up to 40% of cases. This is associated with the presence of aneurysm, dissection, and IMH thickness. Long-term follow-up is mandatory as late interventions occur, particularly for higher risk patients.

Progression of Type B Intramural Hematoma Patients with Obstructive Sleep Apnea

OBJECTIVE

This study aimed to estimate the influence of obstructive sleep apnea (OSA) on type B intramural hematoma (IMHB) progression.

METHODS

All 127 patients received sleep evaluations and esophageal pressure measurements. Variables associated with aorta-related adverse events and mortality were summarized by logistic regression analysis and Cox proportional hazard models. Competing risk analysis of death was used to estimate aorta-related and non-aorta-related mortality.

RESULTS

The OSA group had a higher aorta-related adverse events rate (46% vs. 4%, P<0.001). The mean nighttime systolic pressure (OR, 1.24; 95% CI, 1.11-1.38, P<0.001) was associated with aorta-related adverse events during the acute phase. Thoracic endovascular aortic repair (TEVAR) (HR, 16.2; 95% CI, 7.68-34.22, P<0.001) and mean morning systolic pressure (HR, 1.43; 95% CI, 1.22-1.68, P<0.001) were associated with a higher rate of occurrence of aorta-related adverse events. The occurrence of OSA (HR, 3.19; 95% CI, 2.57-12.15, P<0.001) and mean morning systolic pressure (HR, 1.59; 95% CI, 1.27-2.01, P=0.002) were significantly associated with aorta-related mortality. Competing risk analysis revealed significantly higher aorta-related mortality in the OSA group (11.8% vs. 2.0%, P=0.0412). A neutrophil-to-lymphocyte ratio (NLR) of > 3.52 (specificity: 90.2%, sensitivity: 89.5%) and a mean platelet volume-to-platelet ratio (MPV/PLT) of > 0.049 (specificity: 98.0%, sensitivity: 98.7%) have diagnostic value for detecting OSA in IMHB.

CONCLUSIONS

OSA leads to a higher aorta-related adverse event rate and mortality in patients with IMHB. Variables associated with outcomes include TEVAR, mean morning/nighttime systolic pressure and OSA. The NLR and MPV/PLT ratios are valuable for detecting OSA in IMHB patients.

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.

Certain aortic geometries and hemodynamics are associated with FID development and impact the evolution of uncomplicated type B intramural hematoma during the acute phase

OBJECTIVES

It is difficult to predict the evolution of uncomplicated type B intramural hematoma (IMHB) with a focal intimal disruption (FID) in the acute phase. The aims of this study were to investigate the predictors of FIDs and summarize the risk factors for the evolution of uncomplicated IMHB in the acute phase.

METHODS

Eighty-six patients with uncomplicated IMHB were included and were divided according to the development of an FID during the acute phase: the FID group (n = 32) and the no-FID group (n = 54). Geometric measurements and computed fluid dynamic calculations were based on a computed tomography scan performed on admission. Multivariate logistic regression analysis was used to estimate the predictors of FID development.

RESULTS

Thirty-two (37%) patients developed an FID. Patients with an FID had higher C-reactive protein levels (18.6 ± 2.3 vs 8.1 ± 0.2 mg/dL, P < 0.001) and white blood cell counts (10.3 ± 2.1 vs 7.5 ± 1.7 10⁹ /L, P < 0.001). The no-FID group had lower occurrences of disease progression (15% vs 64%, P < 0.001) and aorta-related mortality (6% vs 25%, P = 0.016). Multivariate logistic regression analysis indicated a significant risk for the occurrence of an FID with a larger maximum aortic diameter (OR, 1.35; 95% CI, 1.05-1.73, P = 0.020), thicker hematoma (OR, 2.20; 95% CI, 1.40-3.48, P = 0.001), and higher oscillatory shear index (per 0.01 unit, OR, 1.74; 95% CI, 1.21-2.49, P = 0.003). The aorta-related mortality during the acute phase was 25% (n = 8).

CONCLUSIONS

Certain aortic conditions, including ta larger aortic diameter, thicker hematoma and higher oscillatory shear stress, are associated with the FID development and result in worse clinical outcomes.

Predictive value of 18F-FDG PET/CT in patients with acute type B aortic intramural hematoma

BACKGROUND

The clinical course and predictors of adverse aortic events (AAE) in patients with acute Stanford type B intramural hematoma (IMH) remain controversial. This study aimed to investigate whether 18F-FDG PET/CT can predict risk in patients with acute type B IMH.

METHODS AND RESULTS

This study included 34 patients with acute type B IMH who underwent PET/CT within 14 days from the onset of symptoms. The maximal standardized uptake values (SUVmax) of 18F-FDG uptake was significantly different between patients with or without AAE (4.3 ± 0.6 vs 3.7 ± 1.0, P = 0.020), but not the target to blood ratio (TBR, SUVmax divided by SUV in the superior vena cava) (1.6 ± 0.2 vs 1.5 ± 0.5, P = 0.064). In patients with initial ulcer-like projection (ULP), a blood-filled pouch protruding into the IMH, which was seen in 25 patients(74%), both the SUVmax and TBR were significantly higher in patients who developed AAE, (4.3 ± 0.6 vs 3.3 ± 0.5, P = 0.001; 1.6 ± 0.2 vs 1.4 ± 0.2, P = 0.01); the TBR >1.5, which is determined from receiver-operating-characteristic curve, had a sensitivity of 73% and a specificity of 80% in predicting AAE.

CONCLUSION

Patients with ULP and high 18F-FDG uptake were more likely to develop AAE and may require closer surveillance with serial imaging.

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.

Midterm results of type B intramural hematoma endovascular treatment

BACKGROUND

Recently, intramural hematoma (IMH) has been characterized as a rare variant of aortic dissection, falling within the acute aortic syndromes (AAS). Although aortic endovascular treatment seems to provide good results, no consensus has been established regarding the optimal management of IMH affecting the descending thoracic aorta (IMH B). The aim of this study was to assess long-term clinical and morphological results of IMH B treated with a stent graft.

METHODS

Between 2002 and 2013, 15 of the 423 (3.5%) consecutive patients with AAS were found to have IMH B. During follow-up, complications related to IMH B were observed in 10 patients, including 5 during the acute period (<14 days). Surgical indications were ulcerations, refractory pain, aneurysm evolution, aortic rupture, and pleural effusion. An endovascular approach was taken for all forms with suitable anatomy.

RESULTS

Technical success rate was 100%, with complete exclusion of lesions of the descending thoracic aorta in all cases treated with a stent graft. No neurological complications or deaths occurred within the first 30 postoperative days, nor at the end of the mean follow-up of 46 months (1-137 months). After the aortic stent graft, partial or complete regression of the hematoma was observed in all cases.

CONCLUSIONS

IMH B is most often a progressive disease requiring long-term monitoring. In case of complications, stent-graft treatment of the descending thoracic aorta can be performed successfully in most cases. This procedure appears to be a safe technique that provides very good long-term results, with favorable remodeling of the aorta.

Endovascular repair of aortic dissection and intramural hematoma: indications and serial changes

Thoracic aortic dissection (AD) is one of the most common aortic emergencies. It can be fatal if not promptly diagnosed and treated. Intramural hematoma (IMH) of the aorta is recognized as distinct from classic (double-barreled) AD. IMH also frequently leads to aortic emergency, which can be fatal unless rapidly diagnosed and treated. Recently, thoracic endovascular aortic repair (TEVAR) has been used for the treatment of complications caused by AD. TEVAR is also a viable option for the treatment of complicated IHM. In this article, we review the details of TEVAR as treatment options for AD and IMH, including the indications for TEVAR, imaging, and follow-up.