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

Abstract

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. The median age at repair was 58.1 years (range 38-86) and 14 (78%) were men. Eight patients (44%) presented with haemopericardium, and 10 (56%) underwent TEVAR within 24h. The mean IMH thickness and AA diameter were 10.4±3.6 and 45.7±4.6mm, 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 7-78). 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. In selected patients with acute retrograde type A IMH, TEVAR offered a treatment alternative to open surgical grafting and medical follow up.