Endovascular Repair for Retrograde Type A Intramural Haematoma with Intimal Tear in the Descending Thoracic Aorta

Abstract

WHAT THIS PAPER ADDS This is the first report with mid term follow up on endovascular thoracic aortic repair for patients with acute retrograde type A intramural haematoma with intimal tear in the descending thoracic aorta. It now includes 18 patients from four institutions and demonstrates that thoracic endovascular aneurysm repair is feasible and a promising alternative for the treatment of this complex type of pathology Objective: The current treatment for acute retrograde type A intramural haematoma (IMH) remains challenging. Aortic remodelling in both the ascending aorta (AA) and descending thoracic aorta (DTA) was evaluated and the 30 day and mid term outcomes were determined in patients who underwent thoracic endovascular aneurysm repair (TEVAR) for retrograde type A IMH with a primary intimal tear or ulcer like projection in the DTA Methods: This was a retrospective, multicentre observational study. Clinical data, including post-operative mortality and adverse event, aorta related re-intervention, aortic remodelling, and the survival rate of 18 non-consecutive patients with acute retrograde type A IMH undergoing TEVAR between June 2006 and March 2018 were reviewed. Results: The median age at repair was 58.1 years (range 38e86) and 14 (78%) were men. Eight patients (44%) presented with haemopericardium, and 10 (56%) underwent TEVAR within 24 h. The mean IMH thickness and AA diameter were 10.4 AE 3.6 and 45.7 AE 4.6 mm, respectively. Among all patients with acute retrograde type A IMH, 11 patients presented with classical type B aortic dissection and seven with type B IMH. All procedures were technically successful. The median follow up was 28.7 months (range 7e78). No 30 day mortality was observed. Three patients developed post-procedure adverse events. Of these, two patients had neurological events, with one each having cerebrovascular and spinal cord infarction individually, and the third patient required long term haemodialysis with ventilator support. The overall survival rate was 100%. The maximum diameter of the AA and the IMH in the AA significantly decreased after TEVAR. Aortic remodelling was also observed in the DTA along the length of TEVAR coverage. Conclusion: In selected patients with acute retrograde type A IMH, TEVAR offered a treatment alternative to open surgical grafting and medical follow up.

Thoracic Endovascular Aortic Repair for Retrograde Type A Aortic Intramural Hematoma

“…By contrast, the effect of TEVAR for re-TAIMH was more striking. In previous studies with a total number of 37 patients, there was no in-hospital mortality, and two patients died in the follow-up of 24 months, of which a cohort including 18 patients achieved 100% overall survival rate and favorable remolding during 28.7 ± 18.9 months (7,8,10,19,23). However, the inadequacy of the sample size reduced the persuasiveness of these studies.…”

“…Re-TAIMH was currently a relatively obscure concept that TAIMH accompanied by PAU or ULP in descending aorta or type B AD was all included (7)(8)(9)(10)12). In recent years, the small tear or rupture of the intima was found in CTA and was confirmed during the operation within some patients with IMH (24)(25)(26).…”

“…While how to treat uncomplicated TAIMH, emergency operation, or initial medical management is still in debate, thoracic endovascular aortic repair (TEVAR) in descending aorta for re-TAIMH is budding and applied successfully in some selected patients (8)(9)(10)(11)(12). The core idea of this technology is to block the PAU or entry tear, which may be the main culprit causing re-TAIMH.…”

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

“…Their outcomes were satisfactory, with the hematoma in ascending aorta completely reabsorbed in all the 8 patients. And very recently, Ryoi et al reported their experience with TEVAR for a series of 18 cases of retrograde type A IMH, among whom 11 presented aortic dissection and 7 presented IMH in descending aorta (11). Another group, Li et al reported TEVAR for 15 cases with type B aortic dissection associated with retrograde type A IMH (27).…”

“…Thoracic endovascular aortic repair (TEVAR) is a less invasive alternative and its value for descending thoracic aortic diseases has been well confirmed (8). And recently several studies have reported the application of TEVAR in retrograde type A IMH or aortic dissection or IMH to exclude the intimal tear in descending aorta (9)(10)(11). TEVAR could be a possible treatment strategy for patients with retrograde type A IMH, but its safety and efficacy are not fully elucidated.…”