Endovascular repair for retrograde type A intramural hematoma with focal intimal disruption in descending aorta

Abstract

Background: This study aims to report the experience of a single center using thoracic endovascular aortic repair (TEVAR) to treat retrograde type A intramural hematoma (IMH) with focal intimal disruption (FID) in descending aorta. Methods: A total of 24 consecutive patients with retrograde type A IMH and complicated with FID in descending aorta underwent TEVAR in our center from 2015 to 2020. Their clinical data, imaging manifestation and follow-up results were retrospectively reviewed and analyzed. Results: The median age of patients was 57.9 years (range, 42-80) and 18 were men (75%). As the preoperative CT angiography showed, the 24 patients developed IMH complicated with different kinds of FIDs in descending aorta [5 had intramural blood pool (IBP), 15 had ulcer-like projection (ULP), 2 had penetrating atherosclerotic ulcer (PAU), and 5 had localized dissection]. Successful deployment of aortic stent graft was achieved in all patients. There was no endoleak, stent graft migration, spinal cord ischemia, stroke, or 30-day mortality observed after TEVAR. The median duration of follow-up was 30.0 months (range, 3-60). As the last follow-up CT angiography showed, most of the patients (23 in 24, 96%) had favorable aortic remodeling. The maximum hematoma thicknesses and maximum diameters of both ascending and descending aorta were significantly decreased. During follow-up, 1 patient developed retrograde type A aortic dissection (RAAD) and underwent open surgery 3 months after TEVAR. 1 patient died of lung cancer 2 years later. There was no aorta-related death observed. Conclusions: TEVAR provides a safe and effective treatment strategy for selected patients with retrograde type A IMH, and FID developed in descending aorta could be the possible treatment target. However, RAAD remains one of the most serious postoperative complications of concern.

Ascending aortic intramural hematoma: current concepts

“…Endovascular repair of TAIMH using zone 0 for landing has already been reported in the literature with comparable outcomes in terms of mortality to open and conservative management, showing a high long-term survival rate (>95%) [35]. Despite that the available data are limited, thoracic endovascular repair (TEVAR) for retrograde TAIMH, in type B dissection, presented favorable immediate mortality [1,35–40]. Endovascular management should be considered when calcification ingression and ulcer progression are detected beyond 15 days after symptoms’ onset while the presence of pericardial effusion justify an intentionally delayed TEVAR until lamella stabilization [10,38].…”

“…During the longterm follow-up, freedom from all-cause mortality (82.0-98.0% vs. 87.8%), re-intervention (82.5 vs. 93.8%), and aortic-related mortality (88.9 vs. 90.9%) were comparable between open and TEVAR for retrograde TAIMH, however with a higher postoperative morbidity for open repair (34% vs. 7%) [34 && ,36 && ,41]. Endovascular management seems to be related with better ascending and descending aortic remodeling with hematoma decrease or even absorption detected in the majority of cases during the mid-and long-term follow-up [35][36][37][38][39][40].…”

“…In these patients with retrograde TAIMH managed with TEVAR, the technical success is estimated at 100% with rare peri-operative aortic complications and re-interventions and, compared to open repair, shorter duration of operation, length of hospital stay and need for intensive care unit [34 ▪▪ ,35,36 ▪▪ ]., Mid-term outcomes show an acceptable adverse event and re-intervention rate, at 5% each, while close surveillance is mandatory to prevent and manage aortic-related complications [37]. Type I endoleak, evolution to typical type A dissection, stent-induced new entry tear (SINE) and hematoma progression are among the commonest and potentially, fatal complications that indicate further interventional or surgical management [38,39,41]. During the long-term follow-up, freedom from all-cause mortality (82.0–98.0% vs. 87.8%), re-intervention (82.5 vs. 93.8%), and aortic-related mortality (88.9 vs. 90.9%) were comparable between open and TEVAR for retrograde TAIMH, however with a higher postoperative morbidity for open repair (34% vs. 7%) [34 ▪▪ ,36 ▪▪ ,41].…”

“…Despite the evolution of endovascular management and its application in very proximal aortic pathologies, TEVAR is not the first line treatment for standard TAIMH while the recent literature represents mainly patients with retrograde TAIMH that underwent TEVAR mainly to the descending aorta, rather than standard cases with typical involvement of the ascending aorta [35,37,39–41]. In these patients with retrograde TAIMH managed with TEVAR, the technical success is estimated at 100% with rare peri-operative aortic complications and re-interventions and, compared to open repair, shorter duration of operation, length of hospital stay and need for intensive care unit [34 ▪▪ ,35,36 ▪▪ ]., Mid-term outcomes show an acceptable adverse event and re-intervention rate, at 5% each, while close surveillance is mandatory to prevent and manage aortic-related complications [37].…”