Medical and surgical management of acute type B aortic intramural hematoma

Abstract Background Acute type B aortic intramural hematoma (IMH) with ulcer-like projections (ULP) is associated with various adverse aortic-related events (AAE) and recommended for preventive endovascular repair as alternative. However, we have no therapeutic criterion on which to decide preventive treatment. Objectives The purpose of this study was to determine the prognostic value and risk stratification of ULP in patients with acute type B IMH for proper treatment. Methods A retrospective study was conducted on 61 consecutive patients with acute type B IMH and with present of ULP from January 2015 to December 2018 in our center. All patients were treated medically initially and CT scans were performed on admission and during follow-up period. Results During a median follow-up of 4.5 months (range, 0.3 to 49.8 months) from onset, 36 patients (59.0%) had composites of adverse aortic events, including 1 patient died for aortic rupture, 6 patients converted to endovascular repair, 6 progressed into aortic dissection, and 28 developed to aortic enlargement. A cutoff value to estimate risk is 6.0 mm for maximal ULP width (72.2% sensitivity and 84.0% specificity) and 4.0 mm for maximal ULP depth (94.4% sensitivity and 52.0% specificity). Patients with widest (P=0.005) or deepest ULP (P=0.019) in aortic arch and proximal descending thoracic aorta had significant poorer aorta-related event-free survival rates. On multivariate analysis, maximal ULP width ≥6.0 mm [hazard ratio (HR) = 2.569, 95% confidence interval (CI):1.157 to 5.705, P=0.020], maximal ULP depth ≥4.0 mm (HR=5.198, 95% CI: 1.154 to 23.420, P=0.032) and widest ULP in aortic arch and proximal descending thoracic aorta (HR=2.363, 95% CI: 1.012 to 5.517, P=0.047) were independently associated with AAE. ULP with both risk location (widest ULP in aortic arch and proximal descending thoracic aorta) and size (maximal ULP width ≥6.0 mm) were significantly associated with a poorer aortic-related event-free survival rate than others (both P<0.001). Conclusions Maximal ULP width ≥6.0 mm, maximal ULP depth ≥4.0 mm and widest ULP in aortic arch and proximal descending thoracic aorta are predictive for progression of acute type B aortic intramural hematoma. For patients with ULP in both risk location and size, preventive endovascular treatment should be considered. Figure 1 Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): This research was supported by grant DFJH201807 from High-level Hospital Construction Project of Guangdong Provincial People's Hospital.

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Analysis of predictive factors for progression of type B aortic intramural hematoma with computed tomography

Journal of Vascular Surgery ◽

10.1067/mva.2002.123683 ◽

2002 ◽

Vol 35 (6) ◽

pp. 1179-1183 ◽

Cited By ~ 67

Author(s):

Eijun Sueyoshi ◽

Tatsuya Imada ◽

Ichiro Sakamoto ◽

Yohjiro Matsuoka ◽

Kuniaki Hayashi

Keyword(s):

Computed Tomography ◽

Predictive Factors ◽

Intramural Hematoma ◽

Type B ◽

Aortic Intramural Hematoma

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Abstract 15182: Acute Complications of Type B Aortic Intramural Hematoma Compared With Classic Aortic Dissection

Circulation ◽

10.1161/circ.142.suppl_3.15182 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Yutaro Miyoshi ◽

Shuichirou Kaji ◽

Akiko Masumoto ◽

Toshiaki Toyota ◽

Taiji Okada ◽

...

Keyword(s):

Aortic Dissection ◽

Hospital Mortality ◽

Clinical Course ◽

Aortic Rupture ◽

Intramural Hematoma ◽

Spinal Ischemia ◽

Type B ◽

Impending Rupture ◽

Acute Complications ◽

Aortic Intramural Hematoma

Introduction: Although acute type B aortic intramural hematoma (B-IMH) is a variant of acute aortic syndrome having similar clinical demographics to type B classic aortic dissection (B-AD), early clinical course including acute complications are not well investigated. The purpose of this study was to investigate early clinical course and acute complications of B-IMH in comparison with that of B-AD. Methods: Clinical features and early clinical course including acute complications were retrospectively analyzed in 270 B-IMH and 177 B-AD consecutive patients who were admitted to our hospital between 1991 and 2020. Acute complications were defined as rupture, impending rupture, re-dissection, and visceral and leg ischemia. Results: As compared with B-AD, B-IMH presented at older age (72±11 vs 62±15 years; p<0.001), predominantly in females (37% vs 25%). During in-hospital courses, limb ischemia and mesenteric ischemia were less common in patients with B-IMH than those with B-AD (0.4% versus 5.1%, p=0.003, 0.4% versus 2.8%, p=0.03; respectively). In contrast, spinal ischemia was more common in B-IMH patients (2.4% versus 0.6%, p=0.05). Aortic rupture and impending rupture were comparable between B-IMH and B-AD patients (5.9% versus 7.3%. p=0.28). Besides, re-dissection was also comparable between two groups (2.2% versus 5.1%, p=0.06). As a result, prevalence of acute complications was significantly lower in patients with B-IMH (8.8% versus 17%, p=0.008). In-hospital mortality rate in B-IMH was significantly lower than that in B-AD (0.4% versus 9.0%, p<0.001). Conclusions: Although patients with B-IMH had lower in-hospital mortality rates than patients with B-AD, significant portion of B-IMH patients had fatal complications including spinal ischemia or aortic rupture. Patients with B-IMH should be carefully observed as well as patients with B-AD patients.

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