Treatment indications for and outcome of endovascular repair of type B intramural aortic hematoma

Abstract

BMT is justified in uncomplicated IMHB. However, IMHB becomes complicated in the majority of patients within 20 days. TEVAR in complicated IMHB is feasible but associated with a substantial aortic reintervention rate, reflecting technical challenges and fragile aortic wall conditions.

Certain aortic geometries and hemodynamics are associated with FID development and impact the evolution of uncomplicated type B intramural hematoma during the acute phase

“…In our study, the occurrence of FIDs was greater than that reported by Moral et al (37% vs 10%, Table ) . The rates of disease progression and mortality were lower in the FID group (63% vs 91%; 25% vs 36%, Table ) and clearly higher than those reported by Bischoff et al (0% mortality) in the no‐FID group . One potential explanation for the high occurrence of FIDs and poor clinical outcome in the no‐FID group in this retrospective study is the inclusion of more severe and less stable cases (Table ), including patients with a maximum aorta diameter ≥ 45 mm 2 and a hematoma thickness ≥ 10 mm.…”

“…One potential explanation for the high occurrence of FIDs and poor clinical outcome in the no‐FID group in this retrospective study is the inclusion of more severe and less stable cases (Table ), including patients with a maximum aorta diameter ≥ 45 mm 2 and a hematoma thickness ≥ 10 mm. 3 Moreover, Bischoff et al also reported similar geometrical changes and worse clinical outcomes in unstable cases. Furthermore, Ye et al suggested that these unstable patients should be classified as “complicated” and treated with prophylactic TEVAR to prevent progression of the hematoma .…”

“…Should these patients have undergone prophylactic TEVAR once an FID had been demonstrated and while the symptoms were controllable? Advocators of performing prophylactic TEVAR once an FID appears have reported better outcomes . In addition, TEVAR would change the geometry of the aorta and affect the survival of patients with a large diameter ascending aorta ( > 4 cm) who would be more likely to develop retrograde type A aortic dissection after TEVAR (42.4 ± 4.1 mm in the FID group).…”

“…We used the Kolmogorov‐Smirnov test to evaluate the normality of the continuous variables . To determine the risk factors for the development of an FID in the acute phase, logistic regression analysis was used to calculate the odds ratio (OR) of the following potential variables: age, white blood cell and the CRP, maximum diameter, hematoma thickness, aortic tortuosity per 0.001 unit, and maximum oscillatory shear index per 0.001 unit (using the method described by Steven et al). Because of the limited number of patients, only three variables (maximum aortic diameter, hematoma thickness, and oscillatory shear index) were included in the multivariate analysis according to the clinical value, collinearity test results and P value ( < 0.20) in the univariate analysis.…”

The evolution of treatments for uncomplicated type B intramural hematoma patients

“…Advocators of the necessary TEVAR procedure for IMHB patients with disease progression and uncontrollable syndromes have reported that it could prevent further progression of IMHB and achieve a better prognosis than medical treatment alone . However, for patients with disease progression and uncontrollable syndromes who lack sufficient medical treatment, the fragile aortic wall will probably result in higher postoperative mortality, which is the major problem with the “watchful waiting strategy.” Therefore, other physicians have advocated a more aggressive treatment (prophylactic TEVAR during the acute phase) for IMHB patients with disease progression when the syndromes were still controllable, and better outcomes than those with the conventional “watchful waiting strategy” have been reported . Moreover, many factors can predict the disease progression and outcome of IMHB patients, such as maximum aortic diameter (≥45 mm), increased pleural effusion, hematoma thickness (≥10 mm), focal intimal disruption (FID) development and an elevated C‐reactive protein (CRP) level (≥7.2 mg/dL) .…”