Thoracic Endovascular Aortic Repair for Retrograde Type A Aortic Intramural Hematoma

Abstract

Objectives: To evaluate the effects of thoracic endovascular aortic repair (TEVAR) in descending aorta for retrograde type A aortic intramural hematoma (re-TAIMH).Methods: From January 2013 to September 2019, 65 consecutive patients diagnosed with re-TAIMH and treated by TEVAR were enrolled in this retrospective cohort study, of whom 44 patients presented with entry tear in descending aorta (Group A) and 21 with penetrating atherosclerotic ulcer (Group B). The clinical data, including baseline characteristics, adverse events, aortic remolding, and overall survival were reviewed.Results: The mean age of all the patients was 52.0 ± 8.3 years, and 54 (83.1%) patients were men. The mean maximal ascending aortic diameter (MAAD) was 43.1 ± 5.4 mm, and the mean maximal ascending aortic hematoma thickness (MAAHT) was 9.6 ± 4.7 mm. TEVAR was performed under general anesthesia in 53 (81.5%) patients, while 12 (18.5%) patients were treated under local anesthesia. There were two deaths during hospitalization (one with rupture and another with multiple organ dysfunction syndrome), and overall survival at 1, 4, and 7 years for all 65 patients was 93.8, 92.0, and 87.4%, respectively. The MAAD and MAATH decreased significantly after TEVAR (p < 0.05) in the two groups, so did the mean descending aortic diameter at the pulmonary bifurcation level. Type I endoleak, dialysis, progression to type A aortic dissection, and enlargement in MAAHT and MAAD were more common complications, which occurred in four, three, two, and two patients, respectively.Conclusion: Patients with retrograde TAIMH treated by TEVAR had a favorable prognosis including late survival and aortic remolding. However, some post-intervention complications were not negligible.

Ascending aortic intramural hematoma: current concepts

“…Despite the evolution of endovascular management and its application in very proximal aortic pathologies, TEVAR is not the first line treatment for standard TAIMH while the recent literature represents mainly patients with retrograde TAIMH that underwent TEVAR mainly to the descending aorta, rather than standard cases with typical involvement of the ascending aorta [35,37,39–41]. In these patients with retrograde TAIMH managed with TEVAR, the technical success is estimated at 100% with rare peri-operative aortic complications and re-interventions and, compared to open repair, shorter duration of operation, length of hospital stay and need for intensive care unit [34 ▪▪ ,35,36 ▪▪ ]., Mid-term outcomes show an acceptable adverse event and re-intervention rate, at 5% each, while close surveillance is mandatory to prevent and manage aortic-related complications [37].…”

“…In these patients with retrograde TAIMH managed with TEVAR, the technical success is estimated at 100% with rare peri-operative aortic complications and re-interventions and, compared to open repair, shorter duration of operation, length of hospital stay and need for intensive care unit [34 ▪▪ ,35,36 ▪▪ ]., Mid-term outcomes show an acceptable adverse event and re-intervention rate, at 5% each, while close surveillance is mandatory to prevent and manage aortic-related complications [37]. Type I endoleak, evolution to typical type A dissection, stent-induced new entry tear (SINE) and hematoma progression are among the commonest and potentially, fatal complications that indicate further interventional or surgical management [38,39,41]. During the long-term follow-up, freedom from all-cause mortality (82.0–98.0% vs. 87.8%), re-intervention (82.5 vs. 93.8%), and aortic-related mortality (88.9 vs. 90.9%) were comparable between open and TEVAR for retrograde TAIMH, however with a higher postoperative morbidity for open repair (34% vs. 7%) [34 ▪▪ ,36 ▪▪ ,41].…”

“…Type I endoleak, evolution to typical type A dissection, stent-induced new entry tear (SINE) and hematoma progression are among the commonest and potentially, fatal complications that indicate further interventional or surgical management [38,39,41]. During the long-term follow-up, freedom from all-cause mortality (82.0–98.0% vs. 87.8%), re-intervention (82.5 vs. 93.8%), and aortic-related mortality (88.9 vs. 90.9%) were comparable between open and TEVAR for retrograde TAIMH, however with a higher postoperative morbidity for open repair (34% vs. 7%) [34 ▪▪ ,36 ▪▪ ,41]. Endovascular management seems to be related with better ascending and descending aortic remodeling with hematoma decrease or even absorption detected in the majority of cases during the mid- and long-term follow-up [35–40].…”