The evolution of treatments for uncomplicated type B intramural hematoma patients

Abstract

Objectives We aimed to investigate whether uncomplicated type B intramural hematoma (IMHB) patients with known evolution predictors could benefit from more aggressive therapy. Methods Retrospective analysis was performed in uncomplicated IMHB patients with evolution predictors between January 2001 and August 2018. Cox proportional hazard models were constructed to identify the specific factors associated with aorta‐related mortality. Results A total of 226 uncomplicated acute IMHB patients with evolution predictors were included. The conventional therapy group included 187 patients, and the other 39 patients received the more aggressive therapy. Aorta‐related mortality in the first year was higher in the conventional therapy group than in the more aggressive therapy group (15% vs 2.5%, P = .035), and more patients died after thoracic endovascular aortic repair (TEVAR) (13 of 27 patients, 48.1% vs 2.5%, P < .001). The more aggressive therapy group had a higher rate of hematoma resolution than the conventional therapy group (81.6% vs 62.2%, P = .024), a lower possibility of hematoma worsening (2.6% vs 17.0%, P = .021), and a lower reintervention rate (0% vs 11.9%, P = .028). Cox regression analysis revealed that a higher rate of focal intimal disruption (FID) development (hazard ratio [HR], 3.99; 95% confidence interval [CI], 1.16‐11.46, P = .010), and a higher C‐reactive protein (CRP) level (HR, 1.27; 95% CI, 1.16‐1.40, P < .001) were associated with increased aorta‐related mortality. Conclusions More aggressive therapy for uncomplicated IMHB patients with evolution predictors during the acute phase may result in better clinical outcomes. A higher rate of FID development and a higher CRP level are associated with increased aorta‐related mortality.

Clinical and Imaging Predictors of Disease Progression in Type B Aortic Intramural Hematomas and Penetrating Aortic Ulcers: A Systematic Review

“…Of these, 17 studies were included in the present review, all observational and retrospective ( Figure 1 ). Two studies only reported on PAUs [ 11 , 14 ], two studies reported on PAUs and IMHs [ 5 , 10 ] and thirteen articles only concentrated on IMHs [ 12 , 13 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ].…”

“…ARM timing was specified in five studies [ 10 , 18 , 19 , 21 , 24 ], and it occurred in the acute phase in 17/433 cases (3.9%). The number of patients undergoing intervention was reported in 12 studies [ 10 , 12 , 13 , 16 , 17 , 18 , 20 , 21 , 22 , 23 , 24 , 25 ], with a rate of 21% during follow-up (241/1147 cases) ( Table 2 ).…”

“…Clinical and laboratory markers of disease progression and/or poor outcome were outlined in five studies [ 15 , 16 , 17 , 18 , 20 ], while in all articles the authors identified imaging predictors ( Table 4 ).…”

“…According to Bolomey et al [ 15 ], factors of poor prognosis were male gender, MAD > 38 mm and circulating lumen diameter >32 mm at the time of disease onset and MAD > 40 mm and circulating lumen diameter >34 mm after one month of PAU appearance. A higher C-reactive protein (CRP) level was connected to poor prognosis according to Chen et al in two reports [ 16 , 18 ], together with FID development and an higher dosage of matrix-metalloproteinase-9 (MMP-9) [ 18 ]. Chen et al [ 18 ] divided their cohort of patients into two groups depending on diabetes mellitus (DM): the group of patients without DM experienced more TEVARs in the acute phase, and the time lapse between disease onset and progression was shorter than patients without DM (6.4 vs. 12 days).…”

“…The presence of ulcers associated with IMHs was linked to AAE in 10 studies [ 10 , 15 , 16 , 18 , 19 , 20 , 21 , 22 , 24 , 25 ], although only seven of them made a distinction between PAUs and ULP or FID [ 10 , 16 , 18 , 19 , 20 , 24 , 25 ]. Piazza et al [ 10 ] identified ULP and IMH extension > three aortic zones as factors related to the risk for intervention [ 10 ].…”