Clinical study
Endovascular Stent-graft Management of Aortic Intramural Hematomas

https://doi.org/10.1016/j.jvir.2009.02.013Get rights and content

Purpose

To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH).

Materials and Methods

From 2000 to 2006, 15 patients (mean age, 67 years; range, 54–83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6–72 months).

Results

The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%.

Conclusions

Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.

Section snippets

Materials and Methods

From August 2000 to October 2006, 69 patients were admitted to our institution for IMH. The Stanford classification of aortic dissection was used to categorize IMH according to the location of the disease. There were 43 type A and 26 type B IMHs. Of these 69 patients, 31 underwent surgical management (type A, n = 30; type B, n = 1) and 23 underwent medical management (type A, n = 9; type B, n = 14). The remaining 15 patients (type A IMH, n = 4; type B IMH, n = 11) underwent endovascular

Indications for Stent-graft Treatment

The main goal of stent-graft treatment in these cases is to cover the intimal tear to prevent progression of the hematoma within the aortic wall (and thereby to prevent an evolution to pericardial rupture or aortic dissection) or evolution of the intimal lesion to aneurysm formation. In cases of IMH without detectable intimal tear, stent-graft management is not indicated because there is no target lesion and covering the thickened wall will not improve it. All the patients included in this

Discussion

Intramural hematoma of the thoracic aorta is a cardiovascular emergency that is responsible for an overall hospital mortality rate of 16%–21% (13, 16, 17) and requires prompt diagnosis and aggressive management. However, a consensus regarding optimal management strategies for this disease has not yet been established (2, 18).

Mortality rates with medical treatment of type A IMH are high, ranging from 36% to 75% (16, 17, 19). In this regard, the standard treatment during the past decade has been

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  • Cited by (37)

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    None of the authors have identified a conflict of interest.

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