Diagnosis of aortic intramural haematoma

Clinical characteristics and outcomes in patients with acute type A aortic intramural hematoma

BACKGROUND

Although type A acute aortic dissection (AAD) including classic double-channel aorta and intramural hematoma (IMH) is a life-threatening condition, the prognostic impact and predictors of IMH remain to be established. The present study evaluated the prevalence, baseline characteristics, and outcomes of IMH as compared with classic non-thrombosed type A AAD.

METHODS

This multicenter registry in Japan retrospectively included 703 patients with type A AAD. IMH was defined as a crescentic or circular area along the ascending aortic wall without contrast enhancement on computed tomography (CT). Non-thrombosed type A AAD was defined as the classic double-channel ascending aorta on contrast-enhanced CT. The primary endpoint was in-hospital mortality.

RESULTS

Of the 703 patients with type A AAD, 312 (44.3%) had IMH. Older age was an only baseline patient factor significantly associated with the presence of IMH in the multivariable analysis. The longitudinal extent of dissection was greater in patients with classic non-thrombosed AAD than those with IMH, resulting in an increased risk of end-organ malperfusion in the classic AAD group. During the hospitalization, 41 (13.1%) and 85 (21.7%) patients with and without IMH died (p < 0.001). IMH was associated with lower in-hospital mortality in a multivariable model, irrespective of age and the implementation of surgery.

CONCLUSIONS

The present study showed that IMH on CT was frequent among patients with type A AAD. Although IMH was more likely to be present in the elderly, its effect on the better survival was independent of age and surgical treatment.

The Role of Multimodality Imaging Approach in Acute Aortic Syndromes: Diagnosis, Complications, and Clinical Management

Acute aortic syndromes are life-threatening conditions with high morbidity and mortality. The principal pathological feature is acute wall damage with possible evolution towards aortic rupture. Accurate and timely diagnosis is mandatory to avoid catastrophic consequences. Indeed, misdiagnosis with other conditions mimicking acute aortic syndromes is associated with premature death. In this view, cardiovascular imaging is necessary for the correct diagnosis and management. Echocardiography, computed tomography, magnetic resonance imaging, and aortography allow for diagnosis, guarantee immediate treatment, and detect associated complications. Multimodality imaging is essential in the diagnostic work-up to confirm or rule out acute aortic syndromes. The aim of this review is to highlight the contemporary evidence on the role of single cardiovascular imaging techniques and multimodality imaging in the diagnosis and management of acute aortic syndromes.

Management of penetrating aortic ulcer and intramural hematoma in the thoracic aorta

Acute aortic syndrome is a broad clinical entity that encompasses several pathologies. Aortic dissection is a well-studied disorder, but the other most prominent disorders within the scope of acute aortic syndrome, penetrating aortic ulcer and intramural hematoma, are more nebulous in terms of their pathophysiology and treatment strategies. While patient risk factors, presenting symptoms, and medical and surgical management strategies are similar to those of aortic dissection, there are indeed nuanced differences unique to penetrating aortic ulcer and intramural hematoma that surgeons and acute care providers must consider while managing patients with these diagnoses. The aim of this review is to summarize patient demographics, pathophysiology, workup, and treatment strategies that are unique to penetrating aortic ulcer and intramural hematoma.

Aortic enlargement in two weeks is associated with subsequent aortic events in patients with type B acute aortic syndrome

OBJECTIVES

To determine whether aortic enlargement in 2 weeks in patients with type B acute aortic syndrome is associated with aorta-related adverse events.

METHODS

This retrospective, single-center study included 183 patients who were diagnosed with uncomplicated type B acute aortic syndrome (classic aortic dissection and intramural hematoma) between 2010 and 2019 and had follow-up computed tomography at second or third week. Aortic diameter was measured at admission and at predischarge follow-up. Aorta-related adverse events were defined by a composite of aortic rupture, surgical or endovascular aortic repair, redissection, severe intestinal malperfusion, and aortic enlargement.

RESULTS

The patients whose aortic diameter enlarged ≥2 mm but <5 mm in 2 weeks were categorized as moderate aortic enlargement group. During follow-up, 51 patients (28%) had aorta-related adverse events and 36 patients (20%) had moderate aortic enlargement. Patients with moderate aortic enlargement showed lower aorta-related event-free survival rates than those without moderate enlargement (48 ± 9% vs 90 ± 3% at 1 year, P < .001). On multivariable analysis, moderate aortic enlargement (subhazard ratio, 3.64; 95% confidence interval, 2.08-6.35; P < .001) and aortic diameter ≥40 mm at admission (subhazard ratio, 2.96; 95% confidence interval, 1.60-5.48; P < .001) were associated with aorta-related adverse events.

CONCLUSIONS

Moderate aortic enlargement in 2 weeks is a significant risk factor of aorta-related adverse events in patients with uncomplicated type B acute aortic syndrome. Patients with moderate aortic enlargement should be followed up carefully and may be candidates for subsequent endovascular treatment.

Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta

OBJECTIVE

The optimal treatment of intramural hematoma (IMH) involving the ascending aorta remains controversial. This study aimed to analyze the results of the management of patients with acute IMH involving the ascending aorta and extending into the descending thoracic aorta, to compare outcomes of descending thoracic endovascular aortic repair (TEVAR) with that of medical therapy (MT), and to assess the risk factors associated with adverse aortic events.

METHODS

We retrospectively analyzed all patients diagnosed with acute IMH involving the ascending aorta and extending into the descending thoracic aorta from January 2012 to December 2019. The primary end points during follow-up were aortic disease-related death and adverse aorta-related events that required surgical or endovascular treatment, such as aortic rupture, the progression of aortic disease, or endoleak.

RESULTS

We identified a total of 135 patients with acute IMH involving the ascending aorta and extending into the descending thoracic aorta, of whom 104 underwent descending TEVAR (group 1) and 31 were managed with MT (group 2). Freedom from adverse aorta-related events at 1, 3, and 5 years was significantly higher for patients who underwent descending TEVAR compared with those managed with MT (89.2%, 88.2%, and 84.0% vs 74.2%, 74.2%, and 74.2%, respectively; P = .026). The 1-, 3-, and 5-year survival rates for patients in the descending TEVAR group was 100%, 100%, and 100%, respectively, which was significantly higher than the survival of the MT group: 93.5%, 93.5%, and 81.9%, respectively (P = .002). On a univariate analysis among patients receiving MT, those who suffered adverse aorta-related events showed a higher prevalence of renal insufficiency (55.6% vs 9.1%; P = .003). In MT patients, multivariate analysis showed that renal insufficiency was the only independent risk factor associated with adverse aorta-related events (hazard ratio, 8.691; 95% confidence interval, 2.056-36.737; P = .003).

CONCLUSIONS

Based on our study, compared with MT, descending TEVAR might be the more favorable treatment for patients with IMH involving the ascending aorta and extending into the descending thoracic aorta. Patients with renal insufficiency are more likely to experience adverse aorta-related events, which implies the need for subsequent intervention or an increased risk of mortality. The risk factor would be helpful for clinical decision-making.

Management of the penetrating atherosclerotic ulcer in the descending thoracic aorta

Penetrating atherosclerotic ulcers present with an insidious onset with a reported mortality of 9%, varying across populations. With vast arrays of risk factors and potentially ominous complications, it is vital to efficiently provide optimum strategies for management. There exists controversy in the literature regarding management, especially for Type B penetrating atherosclerotic ulcers; the decision-making framework encompasses numerous factors in considerations for medical management versus invasive intervention and choice of endovascular versus open repair in the latter. The concomitant presence of intramural haematoma adds further complexity to the already intricate decision-making for management. We performed searches through PubMed and SCOPUS analysing studies reporting outcomes for management strategies for penetrating atherosclerotic ulcers treatment, focusing on Type B, further seeking to analyse studies reporting their experiences of PAU patients with concomitant intramural haematoma. Our review highlights the ambiguity and controversy existing in the literature, comprising studies burdened by their inherent hindering limitations of their single-centre retrospective experiences. Endovascular therapy has come to the forefront of penetrating atherosclerotic ulcers management, often considered first line therapy. In the case of penetrating atherosclerotic ulcers alongside intramural haematoma, there have been reports of potential hybrid surgical approaches to management. Studies further show misdiagnosis of penetrating atherosclerotic ulcers in earlier data sets further complicates management. However, it is clear we must progress on the journey towards precision medicine, allowing delivery of optimum care to our patients.

Differential clinical features and long-term prognosis of acute aortic syndrome according to disease entity

AIMS

To evaluate the acute and long-term prognosis of acute aortic syndrome (AAS) according to the disease entity [intramural haematoma (IMH) vs. aortic dissection (AD)] and the anatomical location (type A vs. B).

METHODS AND RESULTS

A total of 1012 patients [672 with AD and 340 with IMH (33.6%)] were enrolled between 1993 and 2015. Compared with AD patients, IMH patients were older and had higher frequency of female sex and distal aorta involvement. The overall crude in-hospital mortality of AAS was 8.6%; type A AD [15.0%; adjusted hazard ratio (aHR) 30.4; 95% confidence interval (CI) 8.62-107.3; P < 0.001], type A IMH (8.0%; aHR 4.85; 95% CI 1.29-18.2; P = 0.019), type B AD (5.0%; aHR 3.51; 95% CI 1.00-12.4; P = 0.051), and type B IMH [1.5%; aHR 1.00 (reference)]. During a median follow-up duration of 8.5 years (interquartile range: 4.0-13.5 years), AD (aHR 2.78; 95% CI 1.87-4.14; P < 0.001) and type A (aHR 2.28; 95% CI 1.45-3.58; P < 0.001) was associated with a higher risk of aortic death. After 90 days, a risk of aortic death was no longer associated with anatomical location (aHR 0.74; 95% CI 0.40-1.36; P = 0.33), but remained associated with disease entity (aHR 1.83; 95% CI 1.10-3.04; P = 0.02).

CONCLUSION

The clinical features, response to treatment strategy, and outcomes of IMH patients were distinct from those of AD patients. Both early and late survival was better for IMH than for AD. In addition to the anatomical location of AAS, the disease entity is an independent factor associated with both acute and long-term mortality in patients with AAS. Further investigation is necessary to confirm the prognostic implication of disease entity in different patient populations.

Diagnosing Aortic Intramural Hematoma: Current Perspectives

Aortic intramural hematoma (AIH) is an entity within the acute aortic syndrome. Combination of a priori probability, clinical history, laboratory blood test and imaging techniques are the basis for diagnosis of AIH. This review is focused on all aspects related to diagnosis of patients with AIH, from clinical to imaging and analytical.

Prognostic value of clinical and morphologic findings in patients with type B aortic intramural hematoma

Background

Aortic intramural hematoma (IMH) is a subset of acute aortic syndrome, and its prognosis may differ between races. This study aimed to study the prognosis of Chinese type B IMH patients and to find out risk factors.

Methods

A total of 71 type B IMH patients with or without penetrating atherosclerosis ulcer (PAU) administrated in our center between September 2013 and October 2017 were retrospectively studied. Both clinical and imaging data were collected and analyzed. The primary end point was aorta-related death, and the secondary end point was progression, which was defined as enlargement of aorta, increased aortic wall thickness, and aortic dissection or aneurysm formation. Kaplan-Meier survival analysis and Cox regression analysis were used for prognostic analysis.

Results

Among these 71 patients, 21 had simple type B IMH, when 50 had type B IMH in association with PAU. Twenty-five patients received optimal medical therapy (OMT) alone, while 46 patients received surgery and OMT. The mean follow-up time was 27.5 ± 13.5 months. For type B IMH patients, association with PAU indicated poor prognosis and required more intensive management (HR = 16.68, 1.96~141.87), while maximum aortic diameter (MAD) was an independent risk factor (HR = 1.096, 1.016~1.182). For patients with PAU-IMH, MAD was an independent risk factor (HR = 1.04, 1.021~1.194), while surgical treatment was independent protective factor (HR = 0.172, 0.042~0.696).

Conclusion

Association with PAU and MAD were independent risk factors for type B IMH patients. Surgery may improve the outcomes for type B IMH in association with PAU.

Optimal timing of type A intramural hematoma repair

Acute type A aortic intramural hematomas (IMHs) are often included under the spectrum of acute aortic syndromes. The classical definition is the presence of hematoma in the media without identifiable intimal tear. Dissection occurring within two weeks of presentation is defined as acute. Acute type A IMH remains a subject of debate, especially regarding its definition and management. The classical theory of pathogenesis of IMHs is ruptured vasa vasorum in the aortic media. However, the majority of IMHs are now detected with an intimal defect using high-resolution computed tomography and intravascular ultrasound, which implies that IMHs may be a subset of aortic dissections (ADs), with very limited flow in the false lumen. Much controversy remains regarding IMH differences in presentation, diagnosis, and risk for progression. Geographic location and ethnicity, especially Asian vs. Western, possibly affect the natural history and outcomes of acute type A IMH. In this review, we describe the pathophysiology and management strategies for acute type A IMHs.

Treatment outcomes for acute type A aortic dissection with patent false lumen in patients over the age of 80

OBJECTIVES

While reports which focus on the outcomes of conservative treatments for acute type A aortic dissection in patients over the age of 80 are worth considering, recently many studies have reported improved outcomes of surgical treatment. Accordingly, we analyzed the outcomes of surgical and conservative treatments for acute type A aortic dissection with patent false lumen in patients over the age of 80.

METHODS

We retrospectively investigated 70 patients over 80 years in age out of 248 consecutive patients with acute type A aortic dissection between January, 2010, and May, 2015. Of the 70 patients, 44 underwent surgical treatments (ascending replacement in 33 and total arch replacement in 11) and 23 patients underwent conservative medical treatments.

RESULTS

In the surgical treatment, the 30-day mortality rate was 14% (6/44) and the rate of morbidity was 34%. And 17 patients (39%) were discharged home without ambulatory assistance. The actuarial survival rates in the surgical treatment group were 83% and 60% at 1 and 3 years, respectively. The in-hospital death rate of conservative medical treatment was 43% (10/23). Only 26% of the patients having had conservative treatment were discharged home without ambulatory assistance. The actuarial survival rate in the conservative medical group was 8.7% at 1 year.

CONCLUSION

Surgical outcomes of acute type A aortic dissection with patent false lumen were satisfactory in patients aged over 80 in this study by meticulously determining operative indications, depending on the background of each patient.

Acute aortic syndromes and aortic emergencies

Acute aortic syndrome (AAS) and emergencies are relatively uncommon but are considered as life threatening, potentially fatal conditions. Different forms of aortic emergencies/AAS are often clinically indiscernible. Prompt and accurate diagnosis of these entities significantly influences prognosis and guides therapy. We aim to elucidate the pertinent role that radiology plays in the management of acute aortic diseases, with contrast-enhanced computed tomography angiography (CTA) being the most rapid and robust imaging technique.

Emergency Computed Tomography Angiogram of the Chest, Abdomen, and Pelvis

In the setting of blunt trauma, the rapid assessment of internal injuries is essential to prevent potentially fatal outcomes. Computed tomography is a useful diagnostic tool for both screening and diagnosis. In addition to trauma, acute chest syndromes often warrant emergent computed tomographic angiography, looking for etiologies such as aortic aneurysms or complications of aortic aneurysms, or both, pulmonary emboli, as well as other acute vascular process like aortic dissection and Takayasu aortitis. With continued improvements in diagnostic imaging, computed tomographic angiography of the chest, abdominal and pelvis proves to be an effective modality to image the aorta and other major vascular structures.

Multi-component model of intramural hematoma

A novel multi-component model is introduced for studying interaction between blood flow and deforming aortic wall with intramural hematoma (IMH). The aortic wall is simulated by a composite structure submodel representing material properties of the three main wall layers. The IMH is described by a poroelasticity submodel which takes into account both the pressure inside hematoma and its deformation. The submodel of the hematoma is fully coupled with the aortic submodel as well as with the submodel of the pulsatile blood flow. Model simulations are used to investigate the relation between the peak wall stress, hematoma thickness and permeability in patients of different age. The results indicate that an increase in hematoma thickness leads to larger wall stress, which is in agreement with clinical data. Further simulations demonstrate that a hematoma with smaller permeability results in larger wall stress, suggesting that blood coagulation in hematoma might increase its mechanical stability. This is in agreement with previous experimental observations of coagulation having a beneficial effect on the condition of a patient with the IMH.

Reprint of: Early and late outcomes of acute type A aortic dissection with intramural hematoma

INTRODUCTION

Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH). Our purpose was to analyze our experience and report outcomes after repair of acute type A aortic dissection with IMH.

METHODS

We analyzed all patients from a single center who underwent open repair for acute type A aortic dissection with IMH.

RESULTS

Between 2000 and 2013, we performed 418 repairs for acute type A aortic dissection. These were divided into 2 groups of patients: 64 patients (15%) with type A IMH and 354 patients (85%) with typical dissection. Those with IMH were older (62.4 ± 13.9 years vs 56.7 ± 14.7 years; P < .0046) and presented with reduced renal function (ie, glomerular filtration rate) (P < .0341), less frequently with distal malperfusion, and less frequently with rupture (P < .0116). With IMH, the time from presentation to repair was, by strategy, longer (median, 67 vs 6 hours; P < .0001), but no mortality occurred within 3 days of presentation. Mortality with IMH did not differ from typical dissection: 7 out of 64 patients (10.9%) versus 52 out of 354 patients (14.7%; P = .4276). A lower incidence of postoperative dialysis in the IMH group approached significance: 6 out of 63 patients (9.5%) versus 64 out of 347 patients (18.4%; P = .0820). When adjusted for age and renal function, late survival was improved with IMH (P < .0343).

CONCLUSIONS

Repair of acute type A aortic dissection with IMH is associated with significant early morbidity and mortality, differing minimally from typical aortic dissection. Although expectant repair within 3 days may be applied, the purposeful delay imparted little advantage. Improved late outcomes may be seen with IMH, but continued long-term surveillance is required for verification.

Update in acute aortic syndrome: intramural hematoma and incomplete dissection as new disease entities

Acute aortic syndrome is a relatively recent clinical entity. Non-invasive imaging methods, such as computed tomography and transesophageal echocardiography, have contributed significantly to the diagnosis of variant forms of classic aortic dissection, which have become important disease entities in acute aortic syndrome. Imaging findings may result in risk stratification and application of different treatment options, providing a rational approach to achieve a better outcome of this syndrome. This review will focus on the imaging characteristics of two important variant forms of classic aortic dissection, intramural hematoma and incomplete dissection, and the role of imaging methods in the evaluation of differences in the hemodynamic status of false lumens that contributes to patient prognosis.

Eleven years of experience with the neurologic complications in Korean patients with acute aortic dissection: a retrospective study

Background

This study attempts to explore the clinical features, possible mechanisms and prognosis of the neurologic complications in patients with acute aortic dissection (AD).

Methods

Medical records of 278 consecutive patients with AD (165 with type A and 113 with type B dissection) over 11.5 years were retrospectively analyzed for clinical history, CT findings, neurologic complications and outcome. Neurologic complications were classified into early-onset or delayed-onset complications. Independent t-test or Chi-square test (or Fisher exact test) was used for comparing the different groups. Multivariable logistic regression analysis was performed to determine the independent association between variables.

Results

The mean age of the included patients (145 male and 133 female) was 59.4 years (range 19–91 years). 41 patients (14.7%) had a neurologic complication, which included 21 with early-onset complication and 23 with delayed-onset complication, including 3 with both. Advanced age and classic type of dissection were independently associated with the neurologic complication in patients with type A dissection. The most frequent manifestation was ischemic stroke (26 patients, 9.4%), followed by hypoxic encephalopathy (9, 3.2%), ischemic neuropathy (5, 1.8%), spinal cord ischemia (5, 1.8%), seizure (2, 0.7%), hoarseness (1, 0.4%) and septic encephalopathy (1, 0.4%). Overall in-hospital mortality was 10.1%, whereas the complicated group had a mortality rate of 43.9%. Renal impairment, pulse deficit, neurologic complication and nonsurgical treatment were independent variables for determining in-hospital mortality in patients with type A dissection.

Conclusions

The dominance of neurologic symptom in the early stage of AD may make its early diagnosis difficult. Besides chest pain and widened mediastinum in chest x-ray, variable neurologic symptoms including left hemiparesis with asymmetric pulse and hypotension may suggest underlying AD.

Aortic dissection in the outer third of the media: what is the role of the vasa vasorum in the triggering process?

OBJECTIVES

Extensive clinicopathological analyses of aortic dissection have implicated hypertension and genetic abnormalities as the major pathogenic mechanisms. However, previous findings from pathological examinations have often been inconsistent with these mechanisms. In this paper, we suggest a significant role for the vasa vasorum in the aetiology and pathogenesis of aortic dissection.

METHODS

We reviewed records of patients who underwent thoracic aortic dissection repair at our institution between June 2008 and August 2011. Twenty-one patients (10 men, 11 women; mean age, 65.0 ± 12.0 years) underwent surgery with subsequent histopathological examination of the aortic wall. We evaluated the history and histopathological findings of these patients.

RESULTS

Aortic medial changes were observed in all 21 patients. These changes included thinning and sometimes fragmentation of the elastic lamina, as well as atrophy of the smooth muscle cells, with surrounding accumulation of an Alcian blue-positive mucinous substance, mostly adjacent to the dissection. Importantly, the dissection was located in the outer third of the media in 20 of the 21 patients (95.2%). Of these 20, 18 showed histopathological evidence of sclerotic changes of the vasa vasorum, including muscular hyperplasia, elastosis, intimal fibrosis and/or luminal obstruction, and even rupture. These changes may have been secondary to hypertension or peri-aortic changes, leading to degenerative changes in the aortic media and even initiation of dissection.

CONCLUSIONS

Most aortic dissections initially developed in the outer third of the media alongside the vasa vasorum. In this type of aortic dissection, dysfunction of the vasa vasorum may play a key role in long-standing ischaemia or malnutrition of the aortic media.

The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome

BACKGROUND

Transthoracic echocardiography (TTE) has been traditionally considered inadequate for the diagnosis of acute type A aortic syndrome (AAAS). In the last decade, high-resolution probes and harmonic imaging have been implemented in new echocardiographic systems. However, studies assessing the diagnostic accuracy of TTE for the identification of AAAS in large populations using modern ultrasound technology are lacking.

METHODS

The diagnostic value of harmonic imaging TTE was assessed in 270 consecutive patients with suspected AAAS in whom TTE was the initial diagnostic test.

RESULTS

Acute type A aortic syndrome was diagnosed in 67 patients and excluded in 203 patients (disease prevalence 25%). Sixty-two patients had a classic acute type A aortic dissection, and 5, an acute type A intramural hematoma. Image quality achieved was considered optimal in 244 patients (90%). In the whole study population, TTE had sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of AAAS of 87%, 91%, 75%, and 95%, respectively. When evaluating only patients with optimal image quality, these values increased to 97%, 100%, 100%, and 99%, respectively. Forty-seven patients with clear-cut evidence of AAAS were transferred immediately to the operative room, where transesophageal echocardiography confirmed the diagnosis obtained by TTE in all patients.

CONCLUSIONS

Transthoracic echocardiography is a useful imaging modality for the diagnosis of classic acute type A aortic dissection. It cannot be used as the sole screening technique for detecting AAAS, but in the light of the predictive values observed, patients with optimal image quality and clear-cut diagnosis of AAAS should proceed to the operative room, whereas in patients with negative or indeterminate studies, other imaging techniques are needed to refine the diagnosis.

Outcomes of patients with acute type a aortic intramural hematoma

BACKGROUND

The proper treatment option for patients with type A intramural hematoma (IMH), a variant form of classic aortic dissection (AD), remains controversial. We assessed the outcome of our institutional policy of urgent surgery for unstable patients and initial medical treatment for stable patients with surgery in cases with complications.

METHODS AND RESULTS

Among 357 consecutive patients with type A acute aortic syndrome, 101 (28.3%) had IMH and 256 had AD. Urgent operations were performed in 224 patients with AD (87.5%) and 16 with unstable IMH (15.8%; P<0.001). The remaining 85 stable IMH patients received initial medical treatment, and adverse clinical events developed in 31 patients (36.5%) within 6 months, which included development of AD (n=25), delayed surgery (n=25), or death (n=6). Initial aorta diameter and hematoma thickness were independent predictors for development of these events, and the best cutoff values were 55 and 16 mm, respectively. The overall hospital mortality was lower in IMH patients than in AD patients (7.9% [8/101] versus 17.2% [44/256]; P=0.0296) and was comparable to that of surgically treated AD patients (7.9% versus 10.7% [24/224]; P=0.56). The 1-, 2-, and 3-year survival rates of IMH patients were 87.6+/-3.6%, 84.9+/-3.7%, and 83.1+/-4.1%, respectively. There was no statistical difference of overall survival rates between patients with IMH and surgically treated AD patients (P=0.787).

CONCLUSIONS

The clinical outcome of IMH patients receiving treatment by our policy was comparable to that of surgically treated AD patients. However, adverse clinical events were not uncommon with medical treatment alone, and initial aorta diameter and hematoma thickness may identify patients who might benefit from urgent surgery.

Acute Type A Intramural Hematoma

Background— Management of acute type A intramural hematoma (IMH) remains controversial, varying from immediate surgery to medical management only. Conversion to typical dissection remains a concern. We analyzed our experience managing acute type A IMH.

Methods and Results— Between October 1999 and May 2008, 251 patients with acute type A aortic dissection were treated, including 36 (14.3%) with type A IMH. Seven IMH patients (19%) were repaired immediately, 28 (80%) managed initially with optimal medical management and eventual repair and 1 (3%) with medical management only. End points analyzed were early mortality and conversion to typical dissection (flow in the false lumen of the ascending aorta). Time (hours) from onset of symptoms defined initiation of IMH. Early mortality for acute type A IMH was 8.3% (3/36): 14.3% (1/7) with immediate repair and 7.1% (2/28) when optimal medical management with eventual repair was undertaken ( P =0.69). The 1 medically managed Asian patient survived with resolution of the IMH. Conversion to type A IMH to typical dissection occurred in 33% (12/36) of cases. No conversions were observed within 72 hours. Aortic diameter did not predict conversion. In actuarial analysis among the initially medically managed group with eventual repair, the hazard conversion to typical dissection increased significantly at 8 days from the onset of symptoms ( P <0.05).

Conclusions— Despite optimal medical management, conversion of type A IMH to typical dissection still remains a concern, with the most significant risk beyond 8 days. In our patient population, timely surgical repair is recommended.

Endovascular stent-graft management of aortic intramural hematomas

PURPOSE

To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH).

MATERIALS AND METHODS

From 2000 to 2006, 15 patients (mean age, 67 years; range, 54-83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6-72 months).

RESULTS

The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%.

CONCLUSIONS

Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.

Factors associated with in-hospital mortality in patients with acute aortic syndrome involving the ascending aorta

BACKGROUND

Aortic intramural hematoma (IMH), a variant form of classic dissection (AD), is an increasingly recognized and potentially fatal entity of acute aortic syndrome (AAS). We sought to assess the real impact of increased recognition of IMH on mortality of AAS involving the ascending aorta.

METHODS

We evaluated 186 consecutive patients with AAS involving the ascending aorta (57.0+/-13.5 years, 95 females) admitted between January 1993 and March 2003.

RESULTS

Final diagnosis was AD in 135 patients and IMH in 51 (27%). Patients with AD were younger (54.0+/-13 vs. 65.6+/-10.7 years, p<0.05) and surgery was more frequently performed (82% vs. 31%, p<0.001). Overall in-hospital mortality was 16% (30/186); both total mortality (19% vs. 8%, p=0.059) and mortality without surgery (71% vs. 9%, p<0.001) was higher in AD. Logistic regression identified the following presenting variables as predictors of mortality: AD (OR 53.0; 95% CI, 6.6-425.4; p<0.001), confusion/coma (OR 20.1; 95% CI, 3.8-107.8; p<0.001), tamponade (OR 5.3; 95% CI, 1.2-24.3; p=0.031), heart failure (OR 8.1; 95% CI, 1.1-61.0; p=0.043), and medical treatment only (OR 17.6; 95% CI, 4.6-67.6, p<0.001). Tamponade was more prevalent in IMH (25% vs. 11%, p=0.038), and was a predictor of higher mortality in both groups.

CONCLUSION

IMH comprises of significant proportion of AAS involving the ascending aorta and is an independent variable associated with lower mortality despite lower frequency of surgery. Treatment option including optimal timing of surgery can be individualized based on underlying disease entity of AAS and some clinical features at the initial presentation.

Penetrating Atherosclerotic Ulcers of the Infrarenal Aorta: Life-threatening Lesions

OBJECTIVES

To analyze the incidence, clinical features, natural history, and treatment of penetrating atherosclerotic ulcers (PAU) of the abdominal aorta.

MATERIAL AND METHODS

From January 2000 to June 2003, an abdominal PAU was diagnosed at our institution in eight patients (seven men, one woman; mean age 70 year). These eight cases were analyzed together with 38 additional cases found in a review of the literature (total 46 cases).

RESULTS

Occurring at an incidence of approximately 1%, abdominal PAU are less common than thoracic PAU. Seventy percent of cases are symptomatic: pain 52.5% (n =21), acute lower limb ischemia due to distal embolism 12.5% (n =5), shock 5% (n =2). Diagnosis is usually made by CT (66%) (n =26) that demonstrates a PAU in 35% (n =16) of cases, a subadventitial pseudoaneurysm in 28% (n =13), and rupture in 37% (n =17). An intramural hematoma (IMH) is observed in 9% (n =4) of cases. There were no cases of aortic dissection in this series. Calcifications of the abdominal aorta were frequent (56%) (n =26); while intra-aortic mural thrombus was found in 24% of cases (n =11), and 46% of patients (n =21) had an associated aneurysm. Twelve patients were treated medically while 34 underwent surgery (one postoperative death).

CONCLUSION

Review of the literature and this series suggests that PAU of the abdominal aorta is a life-threatening lesion, the main risk being rupture. Surgical management is recommended owing to its low morbidity and mortality.