Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer

Area of Science:

• Cardiovascular Medicine
• Vascular Surgery
• Interventional Radiology

Background:

• Type B aortic intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU) are complex vascular conditions requiring specialized management.
• Current treatment strategies vary, necessitating evidence-based guidelines for optimal patient outcomes.

Purpose of the Study:

• To develop consensus-based treatment algorithms for type B IMH and PAU.
• To review and synthesize existing literature on the management of these aortic pathologies.

Main Methods:

• An expert panel of cardiologists, cardiothoracic surgeons, vascular surgeons, and interventional radiologists convened.
• A systematic literature review of 46 relevant studies involving 1386 patients (925 IMH, 461 PAU) was conducted.
• Consensus methods were employed to formulate treatment recommendations.

Main Results:

• For IMH, 30-day mortality was 3.9%, with 3-year event-related mortality: medical 5.4%, open surgery 23.2%, endovascular 7.1%.
• For PAU, 3-year event-related mortality: open surgery 25.0%, TEVAR 10.4%.
• Immediate intervention is indicated for hemodynamic instability, persistent pain, impending rupture, or progressive hemorrhage. Medical management is suitable for uncomplicated cases, with regular imaging surveillance.

Conclusions:

• Endovascular repair is the preferred treatment for complicated type B aortic PAU and IMH when anatomy is suitable.
• In the chronic phase, aortic diameter >55 mm or rapid expansion (≥ 5 mm/year) warrants consideration for open surgery or thoracic endovascular aortic repair (TEVAR), with TEVAR often preferred.
• Medical management with close monitoring is appropriate for stable, uncomplicated IMH and PAU.