Best Medical Treatment and Selective Stent-GraftRepair for Acute Type B Aortic Intramural Hematoma

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.

Risk stratification of best medical therapy for acute uncomplicated type B intramural hematoma

OBJECTIVES

Best medical therapy (BMT) for acute uncomplicated type B intramural hematoma (TBIMH) is the current treatment guideline, but there is considerable controversy about subsequent clinical course and outcome, which may be associated with a significant failure rate. The purpose of this study was to identify potential risk factors for BMT failure and to develop a risk score to guide clinical decision making.

METHODS

Patients with acute uncomplicated TBIMH between 2011 January and 2020 December were retrospectively studied. Logistic regression was applied to univariately assess potential risk predictors, and multivariable model results were then used to formulate a simplified predictive model for BMT failure.

RESULTS

In a total of 61 patients, the overall rate of BMT failure was 57.4% (35/61), of which 48.6% (17/35) occurred within 28 days of onset. Logistic regression identified maximum descending aortic diameter (HR ​= ​1.99 CI ​= ​1.16-3.40, p ​= ​0.012), initial IMH thickness (HR ​= ​3.29, CI ​= ​1.28-8.46, p ​= ​0.013) and presence of focal contrast enhancement (HR ​= ​3.12, CI ​= ​1.49-6.54, p ​= ​0.003) as potential risk predictors of BMT failure. A risk score was calculated as follows: [Max DTA diameter (mm)∗0.6876 ​+ ​Max IMH thickness (mm)∗1.1918 ​+ ​PAU/ULP ∗1.1369]. Freedom from BMT failure at 1 year was 72% in patients with a risk score ​< ​4.12, compared with only 35.1% in those with a risk score ​≧ ​4.12.

CONCLUSIONS

In a substantial proportion of patients with acute uncomplicated TBIMH, initial BMT failed. Based on the three initial computed tomographic imaging variables, this risk score could help stratify patients at high or low risk for BMT failure and provided additional information for early intervention.

Five Year Results of Endovascular versus Medical Therapy in Acute Type B Aortic Intramural Haematoma: Meta-Analysis of Reconstructed Time to Event Data

OBJECTIVE

To evaluate outcomes in the follow up of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in patients with acute type B aortic intramural haematoma (IMH).

DATA SOURCES

The following sources were searched for articles meeting the inclusion criteria and published by July 2023: PubMed/MEDLINE, EMBASE, CENTRAL/CCTR (Cochrane Controlled Trials Register).

REVIEW METHODS

This systematic review with pooled meta-analysis of time to event data followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and its protocol was registered on the public platform PROSPERO (CRD42023456222). The following were analysed: overall survival (all cause mortality), aortic related mortality, and restricted mean survival time. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool.

RESULTS

Eight studies met the eligibility criteria, including 1 015 patients (440 in the TEVAR group and 575 in the medical therapy group). All studies were observational, and the pooled cohort had a median follow up of 5.1 years. Compared with patients who received medical therapy alone, those who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.44, 95% CI 0.30 - 0.65; p < .001; GRADE certainty: low), lower risk of aortic related death (HR 0.04, 95% CI 0.01 - 0.31; p = .002; GRADE certainty: low) and lifetime gain (restricted mean survival time was overall 201 days longer with TEVAR; p < .001).

CONCLUSION

Thoracic endovascular aortic repair may be associated with lower risk of all cause and aortic related death compared with medical therapy in patients with acute type B IMH; however, the underlying data are not strong enough to draw robust clinical conclusions. Randomised controlled trials with large sample sizes and longer follow up are warranted to elucidate this question.

Thoracic Endovascular Aortic Repair versus Optimal Medical Treatment in Patients with Type B Intramural Hematoma: A Meta-Analysis

PURPOSE

We intended to study the effect of thoracic endovascular aortic repair (TEVAR) and optimal medical treatment (OMT) on type B intramural hematoma (BIMH).

METHODS

We searched PubMed, EMbase, Cochrane Library, and China National Knowledge Infrastructure databases that compared TEVAR and OMT in patients with BIMH. Two authors independently assessed the risk of bias using the Newcastle-Ottawa Scale. The rate ratio (RR) and 95% confidence interval were used to calculate the outcome. The primary endpoints were aortic-related death and regression/resolution. Secondary endpoints were all-cause death, progression to dissection, and secondary intervention.

RESULTS

Eight observational studies were included in the analysis. TEVAR reduced aortic-related death (RR 0.22, 95% CI 0.08-0.56, P = 0.002, I² = 24%) and promoted hematoma regression/resolution (RR 1.48, 95% CI 1.05-2.10, P <0.05, I² = 71%) compared to OMT. Moreover, TEVAR was associated with a reduction in progression to dissection (RR 0.32, 95% CI 0.13-0.81, P <0.02, I² = 39%) and secondary intervention (RR 0.18, 95% CI 0.09-0.37, P <0.00001, I² = 38%) compared to OMT. However, all-cause death has no significant difference between the two groups (RR 0.45, 95% CI 0.17-1.19, P = 0.11, I² = 58%).

CONCLUSIONS

The results of this meta-analysis suggested that TEVAR is an effective treatment for BIMH, which can delay the progression of intramural hematoma and promotes regression/resolution. More research about indications of TEVAR is still needed.

Analysis of Short-Term Clinical Outcomes and Influencing Factors in Patients with Acute Type B Aortic Intramural Hematoma Treated with Optimal Medical Therapy

This study aimed to investigate the short-term predictors of aortic-related adverse events in patients with acute type B aortic intramural hematoma (IMH) initially treated with optimized medical therapy.A total of 157 patients with acute type B IMH were included in this study. These patients were divided into worsening group (n = 45) and stable group (n = 112) based on the incidence of aortic-related adverse events. The clinical data and imaging features of the two groups were compared. Multivariate logistic regression analysis of predictors of aortic-related adverse events in type B IMH was performed. Receiver operating characteristic (ROC) curve was applied to determine the optimal cutoff value for maximum descending aorta diameter (MDAD). Kaplan-Meier survival curve was used to analyze the incidence of aortic-related adverse events.Worsening and stable groups were statistically significant in diuretics, abnormal D-dimer level, observation endpoint systolic blood pressure (SBP), MDAD, aortic atherosclerosis, ulcer-like projection (ULP), and thickness of hematoma (P < 0.05). Multivariate logistic regression showed that abnormal D-dimer level (OR = 12.464, P = 0.025), MDAD (OR = 1.113, P = 0.030), and ULP (OR = 5.849, P = 0.022) were powerful independent risk factors for predicting aortic-related adverse events in type B IMH, and observation endpoint SBP within 100-120 mmHg (OR = 0.225, P = 0.014) was a protective factor for predicting aortic-related adverse events in type B IMH. The cutoff value of MDAD was 35.2 mm.Short-term imaging is recommended for type B IMH patients with abnormal D-dimer level, MDAD > 35.2 mm, and ULP. Blood pressure should also be strictly monitored and controlled during the acute phase of IMH.

Clinical characteristics and outcomes of Stanford type B aortic intramural hematoma: A single centre experience

Objective

To compare the clinical characteristics of Stanford type B aortic intramural hematoma (IMH) and Stanford type B aortic dissection (AD), and to identify the differences between thoracic endovascular aortic repair (TEVAR) and medical management (MM) in the Stanford type B IMH patients.

Methods

A retrospective observational study was conducted in patients treated between January 2015 and December 2016. The clinical characteristics and CT images of patients with type B IMH and type B AD were compared, and the clinical characteristics and CT images of patients in the type B IMH group who were treated with TEVAR and MM were compared.

Results

A total of 176 patients were included in this study, including 62 patients of type B IMH and 114 patients of type B AD. Five patients died in the IMH group and three in the AD group. The proximal hematoma or entry tear in both groups was mainly located in the descending aorta, and the proportion of the iliac artery involved in the AD group was significantly higher than that in the IMH group (31.6% vs. 8.1% P < 0.05). There were 50 MM patients and 12 TEVAR patients in the IMH group. No death occurred in the TEVAR group, while five patients in the MM group died. Seven patients in the MM group had disease progression vs. 12 in the TEVAR group (P < 0.05). The patients in the TEVAR group had more intima lesions than those in the MM group (83.3% vs. 30.0%, P < 0.05). TEVAR group involved more iliac artery hematoma than MM group (33.3% vs. 2.0%, P < 0.05). The maximum thickness of hematoma in TEVAR group was 14.9 ± 3.4 mm, which was significantly larger than that of MM group (10.2 ± 2.8 mm) (P < 0.05).

Conclusion

In the diagnosis of IMH, patients' symptoms and high-risk signs of CTA should be paid attention to. TEVAR therapy should be actively considered on the basis of effective medical management when there are intima lesions (ULP/PAU), increased aortic diameter and hematoma thickness, extensive hematoma involvement, and pleural effusion.

Successful medical treatment of aortic intramural hematoma (Stanford type B) in a patient with aberrant right subclavian artery: A case report

Intramural Hematoma (IMH) forms part of the acute aortic syndrome, aortic dissection, and penetrating aortic ulcer. It is a life-threatening aortic disease that warrants prompt diagnosis and management. Like aortic dissections, it is classified using the Stanford classification system as type A (proximal to the origin of the left subclavian artery) and type B (distal to the origin of the left subclavian artery). Patients with type A IMH is generally managed surgically, and uncomplicated type B IMH is managed medically. The right subclavian artery arises typically from the brachiocephalic trunk. Aberrant right subclavian arteries (ARSA) are rare and derive directly from the aortic arch distal to the left subclavian artery. In this case report, a 73-year-old female presented with right-sided chest pain and shortness of breath. On examination, her heart rate was 100 bpm and blood Pressure was 185/85 and her ECG showed sinus rhythm. Following a CT scan, she was found to have a type B Aortic IMH with an ARSA. She was medically managed with vigorous blood pressure control. After a period of intravenous blood pressure treatment, she was treated with oral medication. Her subsequent CT scan showed that the hematoma was stable. She was followed up with MRI scanning 1 year later, which showed complete healing of the aorta with no changes in diameter. This case illustrates the importance of strict blood pressure management and follow-up imaging in patients presenting with type B IMH. It is important to monitor these patients regularly and where blood pressure control alone is not sufficient, further intervention may be required. Even though the complete resolution may be achieved as in this case, these patients will need to be kept under surveillance with repeated scans to monitor for any changes.

Risk stratification of ulcer-like projection in uncomplicated acute type B aortic intramural haematoma

OBJECTIVES

This study aimed to investigate the morphological evolution and risk stratification of ulcer-like projection (ULP) in patients with uncomplicated acute type B aortic intramural haematoma.

METHODS

A retrospective study was conducted on patients with uncomplicated acute type B intramural haematoma admitted in our institution from January 2015 to June 2020. The primary end points were adverse aortic events (AAE), including aortic rupture, aortic dissection, aortic aneurysm and ULP enlargement.

RESULTS

The study cohort comprised 140 patients, including 62 (44%) and 78 (56%) patients with and without initial ULP, respectively. AAE occurred in 13 patients (9%) in the early term and 42 patients (33%) in the mid-term. Compared with patients without ULP, patients with initial ULP had no significant difference in early outcomes but a higher mid-term AAE rate [8% vs 11%, odds ratio (OR) 1.5, P = 0.47; 17% vs 55%, OR 6.0, P < 0.001]. Significantly higher AAE rate was observed in patients with high-risk ULP (depth ≥5.0 mm and located in the proximal aortic segments) than those with only low-risk ULP (depth <5.0 mm and/or located in the distal aortic segments) (87% vs 51%, OR 6.2, P = 0.014). In the multivariable analysis, high-risk ULP was an independent predictor of AAE (hazard ratio 2.8, P = 0.009).

CONCLUSIONS

High-risk ULP is a rapidly evolving entity and a marker of AAE despite optimal medical therapy. Therefore, close follow-up and prompt intervention are recommended for patients with high-risk ULP.

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.