Natural history and clinical significance of aortic focal intimal flaps

Abstract

ObjectiveFocal intimal flaps (FIF) are a variety of defects of the aorta that result in a short, flap-like projection into the lumen, and are often encountered in asymptomatic patients undergoing computed tomography angiography (CTA) surveillance for aortic aneurysm, but the natural history and clinical significance of such lesions has not yet been studied.MethodsWe retrospectively identified patients with an asymptomatic FIF and available imaging follow-up (>1 year). FIF was defined as flap-like intimal irregularity < 4 cm in length involving the thoracic aorta (TA), abdominal aorta (AA) or common iliac arteries (CIA). FIF characteristics included length and circumferential extent as well as the presence and size (width and depth) of associated penetrating aortic ulcers (PAUs). Patient characteristics, adverse events and history of surgical repair was determined by chart review. FIFs and associated PAUs were assessed for progression by comparing baseline and follow-up CTA studies.ResultsA total of 84 FIFs were identified in 77 patients. Average age was 69.2 ± 10.1 years, and 81% were male (81%). Common co-morbidities included: hypertension (78%), hyperlipidemia (68%), smoking (60%), coronary artery disease (41%), aortic aneurysm (34%), type II diabetes mellitus (27%) and prior cardiovascular surgery (25%). FIFs were most commonly located in the abdominal aorta (n = 50, 60%). Nearly all FIFs were associated with local atherosclerotic plaque (93%). Mean follow-up interval was 3.5 ± 2.6 years (259 cumulative follow-up years). Change in FIF length and local aortic diameter over follow-up were 0.7 ± 2.3 mm and 0.8 ± 1.1 mm, respectively. Nearly half (47%) of FIFs were associated with penetrating aortic ulcers (PAU) with baseline depth of 7.3 mm (IQR: 6.1–10.2) and change in depth of 0.5 ± 1.4 mm. Only 12% of FIFs and 0% of associated PAUs demonstrated growth (≥3 mm) at follow-up. No acute pathology developed in the location of FIFs and no aortic interventions were performed specifically to treat FIFs.ConclusionFocal intimal flaps identified in asymptomatic patients with aortic disease were co-localized with atherosclerotic plaque and PAUs, and demonstrated indolent behavior, not leading to significant growth or acute aortic events, supporting a conservative management approach.

A rare congenital abnormality mimicking the appearance of a type A aortic dissection

“…Classic features of aortic dissection on CTA include intimal flap, double lumen, dilatation of the aorta and intramural haematoma. 3 In this case, an 'intimal flap' was seen on one CTA slice but no double lumen, intramural haematoma or aortic dilatation.…”

The enigma of fine mobile structures on the aortic surface in a patient undergoing transcatheter aortic valve replacement: a case report

“… 8 Most reports on minimal aortic damage involve CT imaging and our images also show abnormalities that might appear linear on CT like the findings in acute trauma patients with very small dissections and thrombi. 9–12 However, our TEE images show a diffuse process with multiple long and very short mobile filaments and no false lumen to indicate a dissection.…”

“…Published still images of minimal aortic injury indicate that the submillimetre resolution of CT might enable the detection of the filamentous structures. 9–12 However, there are reasons why CT may not have been able to demonstrate them in our patient. The CT exam was not tailored to look for this unanticipated finding.…”