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.

Kelvin Jeason Yang,Hsi-Yu Yu,Shoei-Shen Wang,Yih-Sharng Chen,Nai-Hsin Chi,I-Hui Wu

doi:10.3389/fcvm.2021.755214

Abstract

Objective: The optimal treatment modality for retrograde type A intramural hematoma (IMH) remains debatable. This study evaluated and compared surgical outcomes and aortic remodeling after open aortic repair and thoracic endovascular aortic repair (TEVAR) in patients with retrograde type A IMH with a primary intimal tear or ulcer like projection in the descending aorta.Methods: A single center, retrospective observational study was performed on patients with retrograde type A IMH undergoing either open aortic repair and TEVAR. From June 2009 and November 2019, 46 patients with retrograde type A IMH who received either open aortic repair or TEVAR at our institution were reviewed for clinical outcomes, including post-operative mortality/morbidity, re-intervention rate and aortic remodeling.Results: 33 patients underwent open aortic repair and 13 underwent TEVAR. Median age was 68 years (interquartile range [IQR] 15.2 years) and 63 years (IQR 22.5 years) for the open repair group and TEVAR group, respectively. The median duration of follow-up for TEVAR patients was 37.6 months and 40.3 months for open aortic repair. No difference in the 5-year estimated freedom from all-cause mortality (82.1 vs. 87.8%, p = 0.34), re-intervention (82.5 vs. 93.8%, p = 0.08), and aortic-related mortality (88.9 vs. 90.9%, p = 0.88) were observed between the TEVAR and open repair group, respectively; however, the open repair group had a significantly higher 30-day composite morbidity (39.4 vs. 7.7%, p = 0.037). All patients from both treatment groups had complete resolution of the IMH in the ascending aorta. With regard to the descending thoracic aorta, TEVAR group had a significantly greater regression in the diameter of the false lumen or IMH thickness when compared to the open repair group [median 14mm (IQR 10.1) vs. 5mm (IQR 9.5), p < 0.001].Conclusion: TEVAR and open aortic repair were both effective treatments for retrograde type A IMH, in which no residual ascending aortic IMH was observed during follow-up. TEVAR was also associated with lower post-operative composite morbidities and better descending aortic remodeling. In selected patients with retrograde type A IMH, TEVAR might be a safe, effective alternative treatment modality.

Highlights

Type A intramural hematoma (IMH) is defined by the presence of hemorrhage within the wall of the ascending aorta (AA) in the absence of an intimal flap or false lumen (FL) [1, 2]
Individual chart and radiological image review were performed to identify those with retrograde type A IMH with primary intimal tear (IT) or ulcer like projection (ULP) located in the descending thoracic aorta (DTA) who had received treatment at our institution between June 2009 and November 2019 (Figure 1)
The definition of retrograde type A IMH was defined as “the presence of a crescentic or circular high-attenuation area in the AA without contrast enhancement on contrast computed tomography (CT) in either the arterial or venous phase, with typical type B aortic dissection (TBAD) or IMH presenting as primary IT or ULP in the DTA” [10]

Summary

Introduction

Type A intramural hematoma (IMH) is defined by the presence of hemorrhage within the wall of the ascending aorta (AA) in the absence of an intimal flap or false lumen (FL) [1, 2]. When the primary intimal tear (IT) or ulcer like projection (ULP) are present in the descending thoracic aorta (DTA), it is termed retrograde type A IMH. As favorable short and midterm outcomes have been reported in patients who underwent Thoracic Endovascular Aortic Repair (TEVAR) for retrograde type A IMH [7,8,9,10,11], it has been increasingly used either alone or in conjunction with open surgical repair (e.g., Frozen elephant trunk (FET) or open antegrade TEVAR) [12,13,14]. Studies reporting the surgical outcomes of both TEVAR and open repair in the treatment of retrograde type A IMH is lacking. Our study aimed to analyze the outcomes in patients with retrograde type A IMH after isolated TEVAR or open repair at our institution

Methods

Results

Conclusion