Surgery for type A intramural hematoma: a systematic review of clinical outcomes

Abstract

Background: Management of type A intramural hematoma (IMH) remains controversial, with opinions divided as to whether patients should be treated with early aggressive surgery or a more conservative approach. The present systematic review aims to evaluate the mortality and morbidities following surgery for type A IMH. Methods: Electronic searches were performed on five databases from dates of inception to December 2018. All studies with surgical outcomes for type A intramural hematoma were identified by two independent researchers and relevant data extracted. Random-effects meta-analysis of proportions or meta-analysis of means were performed to aggregate the data. Survival data were pooled using reconstructed individual patient data derived from Kaplan-Meier curves. Results: Fifteen studies with 744 patients were identified. Ten studies were from Asian countries (73% of patients). Overall mortality was 8.2% [95% confidence interval (CI): 4.6-13.9%]. Mortality from Asian centers was 5.3% (95% CI: 3.6-7.7%) and 18.9% (95% CI: 7.0-40.4%) in Western centers. Postoperative complications were poorly reported and hence not analyzable. Overall pooled survival of 343 patients from four studies at 1-, 2-, 3-, 5-, and 10-year was 91.8%, 90.2%, 89.2%, 87.7%, and 71.1%, respectively. Conclusions: There is an acceptable level of risk of death after surgery for type A IMH, though significant variations exist between results from Asian and Western centers. More detailed studies are required to clarify the controversies surrounding management of type A IMH.

Outcome Comparison Between Open and Endovascular Aortic Repair for Retrograde Type A Intramural Hematoma With Intimal Tear in the Descending Thoracic Aorta: A Retrospective Observational Study

“…A recently published multi-center study had demonstrated that TEVAR is a safe alternative to open repair, with no 30-day mortality and a low re-intervention rate of only 6%. Post-operative neurological complications developed in two (11.1%) patients and renal/respiratory failure in one (5.6%) ( 10 ), and these numbers were substantially lower than open repair, which were reported to be around 12.9%~31.7% and 9.9% ~ 50.5%, respectively ( 4 , 16 – 18 ). In our study, the short-term composite morbidities were significantly higher for patients after open repair, consisting of post-operative stroke, renal failure and bleeding etc.…”

Medically Managed Type A Thoracic Intramural Hematoma and Penetrating Aortic Ulcer

“…However, it is also important for clinicians to consider IMH as a distinct entity from classical dissections that may benefit even further from maximal medical therapy and subsequent expectant management with delayed surgery or surgery as needed. Patient characteristics and presentation play a large role in making this determination with differing recommendations based on geographical location [11]. The patient in our case benefitted from early, aggressive blood pressure control leading to a stable hemodynamic status that precluded the need for any surgical intervention during their admission.…”

Note the descending aorta: predictors of postoperative major adverse aortic event in pure acute type A intramural hematoma

“…A systematic review of surgical outcomes of ATAIMH identified acceptable risks of postoperative mortality. However, significant heterogeneity exists in the outcomes between Western and Eastern countries (14). Western guidelines recognize IMH as a subset of acute aortic syndrome, and therefore advocate urgent surgery for ATAIMH.…”