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

Coil Embolization for a New Ulcer-Like Projection Near the Distal Anastomosis After a Hemiaortic Arch Replacement

Ulcer-like projections (ULPs) with a tendency to enlarge are at risk of aortic events such as new dissection, aneurysmal formation, or rupture and require therapeutic intervention. However, what should be done after open chest surgery when standard thoracic endovascular aortic repair (TEVAR) cannot be performed is debatable. Here, we present a case of coil embolization of a newly enlarged ULP that was not amenable to TEVAR following a hemiarch aortic arch repair. A 68-year-old male with a history of ascending and hemiaortic arch repair for acute type A aortic dissection presented with a chief complaint of chest pain three months prior to presentation. A post-type A dissection ULP remained in the aortic arch but had enlarged over the three months. Therapeutic intervention was planned to avoid aortic events; however, standard and fenestrated TEVAR were going to be anatomically challenging. Since the patient was in poor general condition after diverticulitis and stroke, reopened total arch replacement and total debranching TEVAR were avoided. The neck of the ULP was narrow and had a small volume; therefore, we assessed that the coil-packing method could embolize the ULP. Coil embolization was successful, and the patient had no postoperative complications. A computed tomography scan at the remote stage showed no recanalization or enlargement, and the patient was stable. Coil embolization may be attempted for arch ULP that can enlarge if the ULP can be embolized with intra-aneurysmal packing when it is difficult to perform a reopen surgery or TEVAR, including standard zone II, total debranching, and fenestrated TEVAR.

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.

A single-center experience of type B aortic intramural hematoma

OBJECTIVE

The outcomes of the best medical treatment (BMT) and intervention treatment (INT) in a single-center experience were reported in type B intramural hematoma (IMH).

METHODS

From February 2015 to February 2021, a total of 195 consecutive patients with type B IMH were enrolled in the study. The primary end point was mortality, and the secondary end points included clinical and imaging outcomes. The clinical outcomes were aortic-related death, retrograde type A aortic dissection, stent graft-induced new entry tear, endoleak, and reintervention. The imaging outcome was evaluated through the latest follow-up computed tomography angiography, which included aortic rupture, aortic dissection, aortic aneurysm, rapid growth of aortic diameter, newly developed or enlarged penetrating aortic ulcer or ulcer-like projection (ULP) and increased aortic wall thickness. Kaplan-Meier curves were used to assess the association between different treatments.

RESULTS

Among the enrolled patients, 115 received BMT, and 80 received INT. There was no significant difference in early (1.7% vs 2.5%; P = 1.00) and midterm all-cause death (8.3% vs 5.2%; P = .42) between the BMT and INT groups. However, patients who underwent INT were at risk of procedure-related complications such as stent graft-induced new entry tear and endoleaks. The INT group was associated with a profound decrease in the risk of ULP, including newly developed ULP (4.3% vs 26.9%; P < .05), ULP enlargement (6.4% vs 31.3%; P < .05), and a lower proportion of high-risk ULP (10.9% vs 45.6%; P < .05). Although there was no significant difference in the incidence of IMH regression between the two groups, the maximum diameter of the descending aorta in patients receiving INT was larger compared with those treated with BMT.

CONCLUSIONS

Based on our limited experience, patients with type B IMH treated with BMT or INT shared similar midterm clinical outcome. Patients who underwent INT may have a decreased risk of ULPs, but a higher risk of procedure-related events and patients on BMT should be closely monitored for ULP progression.