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• W3151036372 abstract "Acute aortic syndrome is defined as interrelated emergency aortic conditions with similar clinical features and challenges, mainly including aortic dissection (AD), intramural haematoma (IMH), penetrating ulcer, and traumatic aorta rupture.1Nienaber C.A. Powell J.T. Management of acute aortic syndromes.Eur Heart J. 2012; 33: 26-35Crossref PubMed Scopus (173) Google Scholar At present, reports on the condition of type B aortic dissection (TBAD) with retrogradce type A IMH are rare, and management of this condition still lacks consensus. Therefore, endovascular management of such conditions is reported in this article. The institutional review board approved this retrospective study. From October 2015 to September 2019, records of 10 patients diagnosed as TBAD with retrograde type A IMH in three medical centres were reviewed. Retrograde type A IMH was defined as a circumferential or crescentic high attenuation area along the ascending aorta without enhancement in both the arterial and venous phase of computed tomography angiography (CTA) with typical TBAD. All patients were male, and none had a personal or family history of connective tissue disorder. There was no contrast in the IMH proximal to the dissection entry tear and no pericardial effusion in any of the cases. The proximal margin of the IMH was above the beginning of the coronary artery and the distal margin varied from the abdominal aorta to the iliac artery (Table 1).Table 1Characteristics of the 10 patients with type B aortic dissection and retrograde type A intramural haematoma (IMH)No.Age – y/SexSymptomsComorbiditiesTIMH – mmDIT-lSA – mmMAAD – mmTEVAR timing – dProximal landing zone143/MChest painHPT8.41.350.4152237/MChest painHPT12.62.644.5143351/MChest painDM18.11.849.833451/MChest painHPT9.25.545.4183556/MBack painHPT10.55.346.5153648/MChest painHPT8.94.543.3193763/MChest painHPT13.56.548.363865/MBack painHPT11.51.949.7163953/MChest painHPT12.14.247.41731049/MChest painHPT9.11.745.2183DIT-LSA = distance between the primary intimal tear and left the subclavian artery; DM = diabetes mellitus; HPT = hypertension; M = male; TIMH = thickness of IMH; MAAD = maximum ascending aortic diameter; TEVAR = thoracic endovascular aortic repair; TEVAR timing = time of treatment from the initial presentation. Open table in a new tab DIT-LSA = distance between the primary intimal tear and left the subclavian artery; DM = diabetes mellitus; HPT = hypertension; M = male; TIMH = thickness of IMH; MAAD = maximum ascending aortic diameter; TEVAR = thoracic endovascular aortic repair; TEVAR timing = time of treatment from the initial presentation. The initial management strategies were based on clinical conditions. Patients with cardiac tamponade, aorta rupture, IMH involving the coronary artery, and signs of cerebral ischaemia underwent open surgery. Urgent thoracic endovascular aortic repair (TEVAR) was performed when patients presented with complicated TBAD (persistent pain, malperfusion), and in the other patients delayed TEVAR with initial medical management was considered; patients with hypertension were monitored and systolic blood pressure was maintained between 100 and 120 mmHg by antihypertensive drugs and a flurbiprofen axetil injection was used to relieve pain. Preliminary aortic CTA was performed to identify the anatomical conditions. TEVAR was then performed by experienced doctors. The true and false lumens, as well as the intimal tear, were confirmed by digital subtraction angiography (DSA). Under DSA guidance the appropriate stent with an oversizing of no more than 10% of the maximum diameter of the aorta (from inner to inner) including the IMH at the proximal landing zone was selected to cover the primary intimal tear. All stents were Medtronic (Minneapolis, MN, USA) and the length ranged from 170 to 200 mm. After the operation, aspirin and clopidogrel were given routinely for three to six months. For all patients, the follow up protocol included assessment of clinical symptoms, survival, and CTA images at one, three, six, and 12 months and then annually thereafter. Follow up data were obtained by reviewing medical records and telephone interview. The technical success rate of TEVAR was 100%. Two patients (cases 3 and 7) underwent urgent TEVAR due to persistent pain, and the remaining eight patients underwent delayed TEVAR. No procedure related complications, defined as death, paralysis, and cerebral ischaemia, were noted in the peri-operative period. All patients were discharged symptom free. During a mean follow up of 29.8 months (6 – 46 months), there was no recurrence of symptoms, and the latest CTA images showed that all the IMHs in the ascending aorta and the false lumens at stent level were completely absorbed. The incidence of IMH in AD patients varies between 10% and 30% in the literature, and IMH frequently involves the descending aorta (58%) rather than the arch or ascending aorta (42%).2Nauta F. de Beaufort H. Mussa F.F. De Vincentiis C. Omura A. Matsuda H. et al.Management of retrograde type A IMH with acute arch tear/type B dissection.Ann Cardiothorac Surg. 2019; 8: 531-539Crossref PubMed Scopus (6) Google Scholar Under the latter conditions, the risk of neurological or cardiac complications and mortality is higher, and therefore an open surgical or hybrid approach has been proposed as the most appropriate treatment method,3Erbel R. Aboyans V. Boileau C. Bossone E. Bartolomeo R.D. Eggebrecht H. et al.ESC Guidelines on the diagnosis and treatment of aortic diseases.Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (2471) Google Scholar,4Czerny M. Schmidli J. Adler S. van den Berg J.C. Bertoglio L. Carrel T. et al.Editor’s Choice – Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2019; 57: 165-198Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar but open surgery is a maximally invasive treatment. In this study, all the patients underwent TEVAR, which aims to exclude the primary intimal tear in the descending aorta, and all the patients had good outcomes. Haenen et al.5Haenen F.W.N. Van Der Weijde E. Vos J. Vos J.A. Heijmen R.H. Retrograde type A intramural hematoma treated endovascularly in two cases.Ann Vasc Surg. 2019; 59: 312-315Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar reported two patients who underwent TEVAR for acute TBAD with type A IMH and also showed good outcomes. Thus, TEVAR may be an acceptable treatment option for patients in this condition. When performing TEVAR, choosing appropriate stents is very important to prevent the IMH from escalating into AD. In this study, the oversizing of the stent was no more than 10% larger than the maximum diameter of the aorta (from inner to inner) including the IMH at the proximal landing zone, and the limited results of the cases confirmed its safety and efficacy. Inflammation and oedema occurred in the arterial wall and intimal tear in the acute stage of AD, in which the aortic wall is relatively fragile and vulnerable to damage thus making it prone to serious complications when operating in this period. Thus, it is recommended that TEVAR is performed after the acute stage (> 14 days after the onset of symptom), which may minimise the risk of retrograde tear. The appropriate time to perform TEVAR still needs further study with a larger sample size. The study demonstrated that covering the entry tear by TEVAR might be an acceptable solution in patients with TBAD and IMH of the ascending aorta in selected patients. None." @default.
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• W3151036372 date "2021-07-01" @default.
• W3151036372 modified "2023-09-29" @default.
• W3151036372 title "Endovascular Stent Graft Treatment of Stanford Type B Aortic Dissection with Retrograde Type A Intramural Haematoma: A Multicentre Retrospective Study" @default.
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• W3151036372 doi "https://doi.org/10.1016/j.ejvs.2021.02.027" @default.
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