Clinical Study
Acute Intramural Hematoma of the Descending Aorta Treated with Stent Graft Repair Is Associated with a Better Prognosis

https://doi.org/10.1016/j.jvir.2017.06.034Get rights and content

Abstract

Purpose

To compare midterm outcomes of optimal medical treatment (OMT) alone with OMT and thoracic endovascular aortic repair (TEVAR) of acute type B intramural hematoma (IMHB).

Materials and Methods

Retrospective analysis was performed of 65 patients treated with OMT alone (31 patients) or OMT with TEVAR (34 patients) for acute uncomplicated or complicated IMHB from January 2006 to December 2015 in a single institution. Primary outcome was aortic-related mortality during follow-up. Secondary outcomes were aortic-related adverse events, all-cause mortality, and occurrence of complete aortic remodeling.

Results

Except for the morphologic nature of the aortic lesion, no significant differences in baseline characteristics between the 2 groups were observed. Mean follow-up time was 32 months ± 19 (range, 1–120 months). Patients in the OMT group had a significantly increased rate of aortic-related mortality (12.9% vs 0% in TEVAR group, P = .046) and aortic-related adverse events (29.0% vs 0% in TEVAR group, P < .001) and an insignificant but higher trending all-cause mortality rate (38.8% vs 19.8% in TEVAR group, P = .15). The occurrence of complete aortic remodeling was significantly lower in the OMT group (15.4% vs 82.1% in TEVAR group, P < .001).

Conclusions

TEVAR is likely to protect from progression of IMHB and to be associated with a better prognosis than OMT alone.

Section snippets

Patient Characteristics

The study protocol was reviewed and approved by the local medical ethics committee and institutional review board. This retrospective study comprised 65 patients with acute complicated or uncomplicated IMHB initially treated with TEVAR (TEVAR group, n = 34 patients) or OMT (OMT group, n = 31 patients) in a single institution between January 2006 and December 2015. Patients’ records were reviewed for demographic characteristics, concomitant diseases, morphologic nature of the aortic lesion,

Procedural Information

The procedural details of TEVAR are presented in Table 2. Technically successful TEVAR was performed in all patients with no procedure-related deaths (Fig E1a–f [available online at www.jvir.org]). There were 7 adjunctive procedures performed in 6 patients. One patient underwent arch debranching (left common carotid–to–left subclavian artery bypass), 2 patients underwent laser fenestration for the left subclavian artery, 1 patient underwent laser fenestration for both the left common carotid

Discussion

The main findings of this study were as follows: (a) Patients with IMHB have diverse clinical features but a much better long-term prognosis when treated with stent graft versus nonsurgical medical therapy. (b) Uncomplicated IMHB can progress to complicated IMHB, which can be a lethal condition. Therefore, the current indications for TEVAR for IMHB may require further modification. (c) Among patients treated with OMT, almost all aortic-related adverse events occurred in the first 6 months of

Acknowledgments

This study was financially supported by the National Natural Science Foundation of China (81500371) and the Science and Technology Committee of Shanghai (SHDC12015112, 15411967300, and 134119a2100). K.Y. gratefully acknowledges the support of Shanghai JiaoTong University K. C. Wong Medical Fellowship fund.

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      Citation Excerpt :

      Endovascular lining of the aorta would promote aortic remodeling by sealing off potential microtears in the intima in “idiopathic” IMH and the ulcer in patients with IMH and concomitant PAU. Aortic endograft stenting has been reported by several institutions to expedite aortic healing, improve symptomatology, and improve aortic-related survival.9-11,37 All patients seem to have experienced improved aortic remodeling regardless of the presence of PAU or not.

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    None of the authors have identified a conflict of interest.

    Figures E1 and E2 are available online at www.jvir.org.

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