Clinical Outcomes of Medical Therapy and Timely Operation in Initially Diagnosed Type A Aortic Intramural Hematoma

Abstract

Background-The management of aortic intramural hematoma (IMH) involving the ascending aorta (type A) has not been well-established. The purpose of this study was to clarify the long-term clinical outcomes of patients with type A IMH who were treated with medical therapy and timely operation. Methods and Results-Clinical data including operative mortality, IMH-related events, and long-term survival were retrospectively reviewed in 66 patients with type A IMH, who were admitted to our institution from 1986 to 2006. Emergent surgical repair was performed in 16 (24%) patients because of severe complications, whereas 50 patients were treated with initial medical therapy. In medically treated patients, 15 (30%) patients who demonstrated progression to classic dissection or increase in hematoma size within 30 days underwent surgical repair except for 2 patients who refused surgery. The 30-day mortality rate was 6% with emergent surgery and 4% with supportive medial therapy. There were 7 late deaths and the actuarial survival rates of all patients were 96Ϯ3%, 94Ϯ3%, and 89Ϯ5% at 1, 5, and 10 years, respectively. In medically treated patients, maximum aortic diameter was the only predictor of early and late progression of ascending IMH (hazard ratio, 4.43; 95% CI, 2.04 -9.64; PϽ0.001). Aortic diameter Ն50 mm predicted progression of ascending IMH with the positive and negative value of 83% and 84%, respectively. Conclusions-Combination

Acute aortic syndrome

“…The proportion of patients who eventually required urgent surgery was 32% in Song's study and similar to other reported series (27,31,33). Song and others identified aortic diameter (>50-55 mm) and thickness of the IMH (>10-16 mm) as risk factors for death, rupture and conversion to AD in patients who are medically treated (27,33).…”

“…The proportion of AAS that is diagnosed as IMH is larger in Asians vs. Americans and Europeans (31). Some Asians (Japanese and Koreans) can be managed initially without surgery and surgery is reserved for those who develop complications of the IMH with very good outcomes (27,33). However, in North Americans, Europeans and Chinese, the mortality of medical management is prohibitively high and emergent or urgent surgical intervention is recommended (24,25,30,32).…”

Outcomes and management of type A intramural hematoma

“…Despite the present gaps in our knowledge of their natural history, popular management approach for ATAIMH, especially in the Western experience (IRAD, Stanford, and other North American authors), continues to be similar to that of ATAAD involving urgent aortic repair (3,(5)(6)(7). On the other hand, most studies from the Far East recommend initial medical management, with surgery reserved for specific circumstances complicating the course of otherwise stable ATAIMH patients and have reported acceptable early and late outcomes (8)(9)(10). Table 1 highlights some of the major differences in the literature reporting experience in management of ATAIMH from the Western vs. Eastern centers.…”

Acute aorta, overview of acute CT findings and endovascular treatment options

“…19 ). In high risk patients without aortic dilatation (< 50 mm) and wall hematoma < 11 mm only medical therapy (hypertension and pain control) can be considered as initial treatment with follow-up CT examination 19,29 .…”