Watch-and-wait strategy for type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta: a Japanese single-centre experience

Abstract

OBJECTIVES In this study, we investigated the early and midterm outcomes of initial watch-and-wait strategy for Stanford type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta in patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection in the ascending aorta. METHODS Inpatient and outpatient records were retrospectively reviewed. RESULTS Of the 81 patients with type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta between April 2011 and April 2019, a watch-and-wait strategy was selected in 46 patients. The mean age of the patients was 68 years, and 22 (48%) patients were female. Ten patients underwent emergency pericardial drainage for cardiac tamponade at the time of presentation and 8 patients underwent aortic repair during hospitalization for new ulcer-like projection, re-dissection or rupture. In-hospital mortality occurred in 2 (4%) patients. During follow-up, survival at 1 and 2 years was 95% and 92%, respectively. There was no significant difference in survival or aortic events between patients in whom the watch-and-wait strategy and emergency surgical treatment were indicated. CONCLUSIONS The early and midterm outcomes of the initial watch-and-wait strategy were favourable for type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta in Japanese patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection. Further study is required to show the safety of this strategy.

The ascending aorta and arch in the sights of transcatheter therapy: A time for reappraisal

“…In-hospital mortality occurred in 4% of patients; during follow-up, the survival at 1 and 2 years was 95% and 92%, respectively. 7 These results have been reproduced by other centers, and Kitai et al…”

“…Kitamura et al reported that the watch‐and‐wait strategy was selected in 46 patients, and 10 of them underwent emergency pericardial drainage for cardiac tamponade at the time of presentation. In‐hospital mortality occurred in 4% of patients; during follow‐up, the survival at 1 and 2 years was 95% and 92%, respectively 7 . These results have been reproduced by other centers, and Kitai et al reported long‐term clinical outcomes of 66 patients with type A IMH who were treated with emergent procedure or medical therapy and timely operation.…”

“…Clearly, there are subgroups for which urgent surgery is not beneficial and indeed harmful, and recent evidence brings paradoxical findings, where in acute type A AAD, the watch‐and‐wait strategy was employed in a selected cohort of patients with intramural hematoma (IMH) and AAD with thrombosed false lumen of the ascending aorta, showing outcomes even superior to emergency surgery 7 . Kitamura et al reported that the watch‐and‐wait strategy was selected in 46 patients, and 10 of them underwent emergency pericardial drainage for cardiac tamponade at the time of presentation.…”

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

“…The optimal timing for TEVAR applied in retrograde type A IMH remains a controversial issue. Typically, urgent surgical repair is recommended for type A IMH or aortic dissection, but studies have demonstrated that initial medical management with timely interventions or the "Watch-and-wait strategy" could achieve good outcomes for retrograde type A IMH or aortic dissection (28)(29)(30). As retrograde type A IMH or aortic dissection showed more favorable prognosis than antegrade type A IMH or aortic dissection which had intimal tear in ascending aorta.…”

Type A Intramural Hematoma

“…Based on the preceding and similar evidence, the Japanese Circulation Society guidelines recommend medical rather than surgical management of uncomplicated type A IMH provided that there are no ulcer-like projections in the ascending aorta, the hematoma thickness is <11 mm, and the aortic diameter is <50 mm ( 10 ). A 2020 report from Japan followed those guidelines with favorable outcomes, but the authors consider their strategy more akin to “watch and wait” than simply medical management, highlighting the fact that they repeated CT angiography at days 1, 3, 7, and 14 following admission ( 11 ).…”