Best Medical Treatment and Selective Stent-GraftRepair for Acute Type B Aortic Intramural Hematoma

Area of Science:

• Cardiovascular Surgery
• Vascular Surgery
• Interventional Cardiology

Background:

• Acute type B aortic intramural hematoma (B-IMH) is a variant of acute aortic dissection.
• Management strategies for B-IMH, particularly the role of stent-graft (SG) repair, require further elucidation.
• Ulcer-like projections on computed tomography angiography may predict the need for intervention in B-IMH patients.

Purpose of the Study:

• To describe the management and outcomes of stent-graft (SG) repair for acute type B aortic intramural hematoma (B-IMH).
• To evaluate early and long-term survival, aortic remodeling, freedom from aortic-related mortality (ARM), and freedom from reintervention after SG repair.
• To compare outcomes between patients treated with SG in acute versus chronic phases and assess the impact of medical management alone.

Main Methods:

• Retrospective analysis of 41 patients with B-IMH treated between January 2005 and July 2016.
• Thirty-one patients underwent SG repair, with interventions performed in acute, subacute, and chronic phases.
• Assessment of major end points including survival, aortic remodeling, ARM, and reintervention rates, with a median follow-up of 31 months.

Main Results:

• Thirty-one (76%) patients underwent SG repair, with 16 in the acute phase and 6 in the subacute phase.
• Nine (29%) patients required SG repair in the chronic phase due to aortic lesion progression despite medical management.
• At 12 months, SG repair showed a trend towards lower ARM (84% ± 10 vs. 100%; P=.075) but significantly lower freedom from aortic progression (64% ± 13 vs. 94% ± 5; P=.002).
• Freedom from ARM and reintervention was 92% ± 5 at 12 months. Aortic remodeling was observed in 84% of patients.
• Best medical treatment alone was associated with a 47% adverse aortic event rate in follow-up.

Conclusions:

• Stent-graft repair for B-IMH is associated with encouraging mid-term results, including high rates of aortic remodeling and freedom from aortic-related mortality and reintervention.
• The presence of ulcer-like projections on initial computed tomography angiography is a significant predictor for requiring SG repair.
• While SG repair may reduce ARM, it is associated with a higher rate of aortic progression compared to best medical treatment alone, highlighting the need for careful patient selection and monitoring.