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

CT characteristics and clinical implications of acute type A aortic intramural hematoma

Objectives

Computed tomography (CT) has been increasingly used in the diagnosis of acute aortic syndrome, and a number of high-risk CT imaging features have been reported. We aimed to identify CT imaging findings suggesting high-risk for acute aortic syndrome by examining clinical outcomes of patients with acute type A aortic intramural hematoma (TAIMH).

Methods

This retrospective study analyzed the relationship of clinical patient characteristics and imaging features with mortality and aortic events in 63 patients receiving initial medical treatment for TAIMH. Multivariate regression analysis was used to determine the predictors of aortic events, and the Kaplan-Meier method was used to analyze survival and aortic events.

Results

During a median follow-up of 4.2 years, 25 patients experienced aortic events and 40% of these occurred within 7 days of admission. In total, 12 patients experienced aortic death and 12 patients underwent open aortic surgery or endovascular stenting for aortic disease. In multivariate regression analysis, penetrating atherosclerotic ulcers (PAUs) or ulcer-like projections (ULPs) (P = 0.04) and pericardial effusion (P = 0.03) were independent predictors of aortic events. In the Cox regression model, PAUs/ULPs (P = 0.04) and pericardial effusion (P = 0.04) were independently associated with lower aortic event-free survival.

Conclusion

Identification of high-risk CT features is important for clinical decision-making during TAIMH treatment. Early and frequent CT imaging follow-up is required in patients receiving medical treatment. PAUs/ULP and pericardial effusion were the strongest predictors of adverse aortic events.

Single-branched stent-graft with on-table fenestration for endovascular repair of primary retrograde type A aortic dissection: A multicenter retrospective study

Objective

This study aims to evaluate the feasibility, efficacy, and safety of a single-branched stent-graft with on-table fenestration for primary retrograde type A aortic dissection (RTAD) during thoracic endovascular aortic repair (TEVAR).

Materials and methods

From January 2019 to December 2021, 36 patients with primary RTAD from five tertiary hospitals received medical management in the acute phase. They underwent TEVAR with a proximal zone 1 landing for aortic arch reconstruction in the subacute phase, using a fenestration technique on a single-branched stent-graft. Nearly 2 weeks after admission, computed tomography angiography (CTA) was re-examined to evaluate the thrombosis status of retrograde false lumen (FL). The primary outcomes were technical success, patency of the target branch arteries, and absence of type Ia endoleaks. The second outcomes were stent-graft-related complications and all-cause mortality.

Results

The mean age was 56.2 ± 11.3 years, and 29 (80.6%) were male. After a median interval of 18.0 [interquartile range (IQR), 17.0–20.3] days of medical treatment, the partial and complete thrombosis of proximal FL rates increased to 52.8% and 47.2%, respectively. One patient (2.8%) experienced postoperative type Ia endoleaks, and was successfully re-treated using coli and Onyx glue. The median hospital stay was 20.5 (IQR, 18.0–23.0) days. The overall technical success rate was 100%. The median follow-up time was 31.5 (IQR, 29.8–34.0) months. There was one death (2.8%) due to gastrointestinal bleeding. Distal aortic segmental enlargement (DASE) occurred in two (5.6%) patients. No major complications or recurrent dissections in the proximal landing zone were recorded during follow up.

Conclusion

The retrograde FL in primary RTAD could realize partial or complete thrombosis after medical management in the acute phase, and it might be regarded as a valid proximal landing zone for endovascular repair. The single-branched stent graft with on-table fenestration performed in the subacute phase may be feasible strategy in selective primary RTAD patients.

Ascending aortic intramural hematoma: current concepts

PURPOSE OF REVIEW

Type A intramural hematoma (TAIMH) is an acute aortic disease characterized by the presence of hematoma in the aortic media and involving the ascending aorta. Open repair seems to be the first treatment approach, although recent evidence highlights that the best management of TAIMH is controversial. This review will focus on the current concept for TAIMH management and factors affecting the decision making.

RECENT FINDINGS

Recent studies have evaluated the role of open and endovascular repair, as well as conservative management in patients with TAIMH. More specific imaging findings seem to affect decision making for urgent repair.

SUMMARY

Despite TAIMH's acute nature, conservative management seems to represent a valid option for urgent approach, presenting similar mortality to open and endovascular repair. Comparative data are limited, however, in experienced centers, any approach may be applied with encouraging results. Endovascular management, which is mainly applied to manage retrograde TAIMH, is related to lower mortality and morbidity compared to open repair in this group of patients while aortic remodeling seems beneficial with this approach. Imaging findings, as ulcer-like lesions, hematoma thickness, concomitant dissection and aortic diameter, related to higher complication rate, set the indication for interventional management. Further research, including prospective data and registries, and ideally, randomized data may further clarify the best approach and factors indicating urgent repair.

Management of Ascending Aorta and Aortic Arch: Similarities and Differences Among Cardiovascular Guidelines

BACKGROUND

Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence.

METHODS

The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases.

RESULTS

The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited.

CONCLUSION

In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.

A Review on the Surgical Management of Intramural Haematoma of the Aorta

Intramural haematoma (IMH) of the aorta is one of the causes of acute aortic syndrome which often requires emergency or urgent life-saving surgery. In this review, we discuss the pathophysiology, epidemiology, clinical presentation, diagnostic imaging, surgery and clinical outcomes associated with IMH.

Broken-crescent sign at CT indicates impending aortic rupture in patients with acute aortic intramural hematoma

Background

This retrospective study evaluated the computed tomography (CT) features and clinical implications of a novel broken-crescent sign in patients with acute aortic intramural hematoma (IMH).

Methods

Out of 104 patients with aortic IMH encountered in our institution between 2003 and 2018, nine patients exhibited a positive broken-crescent sign, which was defined as a focal defect within the hyper-attenuating crescentic IMH on unenhanced CT, corresponding to a smooth out-bulging of the aortic lumen on enhanced study. The clinical findings, CT features, and outcomes of these nine patients were analyzed.

Results

Of five males and four females (age range 48–84 years, mean 69.7 years), six had type A and three had type B IMH. Five patients who had medical treatment and stable status for 1 to 3 days suffered sudden death, two of whom showed ascending aortic rupture with hemopericardium in one and adventitial tear with outward spillage of IMH in another at follow-up CT. The other four patients had early surgical or endovascular management survived; two demonstrated ascending aorta ecchymosis with adventitial tear and intact intima at surgery. Our results support the supposition that aortic IMH complicated with adventitial tear and partial outward seepage of IMH may generate a broken-crescent sign in CT. Despite initially stable clinical status, the residual intact inner aortic wall carries a high risk of sudden aortic rupture.

Conclusions

In patients with acute aortic IMH, identification of a broken-crescent sign in CT is highly suggestive of impending aortic rupture, and early aggressive treatment is mandatory.