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Intramural hematoma (IMH) is defined as a special subgroup of aortic dissection without an identifiable intimal tear and lack of flow in the false lumen of the aorta. It is typically recognized by preoperative imaging techniques by crescentic or, in some cases, circumferential thickening of the aortic wall without imaging evidence of an entry point. Acute type A IMH (TAIMH) is an important subtype of an acute aortic syndrome that presents with symptoms similar to those of aortic dissection. Management of acute TAIMH remains controversial, varying from surgery to endovascular repair or medical management. This was the first study to evaluate the application of thoracic endovascular aortic repair (TEVAR) in the treatment of TAIMH.
From January 2013 to December 2015, 34 TAIMH patients were included in this retrospective study. There were 21 males and 13 females, with age 42∼75 years old. Of them, 16 cases were TAIMH with penetrating aortic ulcer (PAU) located in ascending aorta or arch, and 18 cases were TAIMH with PAU located in descending aorta. The indications for TEVAR were as follows: (1) no signs of severe aortic regurgitation or severe hemodynamic disorder; (2) no signs of ischemia of coronary artery or arch branches; (3) no previous history of cardiac or aortic surgery; (4) role out the possibility of Marfan syndrome or other connective tissue disorders; (5) for TAIMH patients with PAU, PAU should be located in the middle of ascending aorta, at least 1.5 cm from aortic valve or coronary orifice; or in the lesser curvature of aortic arch; or in descending aorta.
According to the following situations (location of PAU, morphology of aortic arch, distribution style of neck vessels of aortic arch, landing zone, patient’s age and general condition), personalized TEVAR strategy was made as follows; (1) endovascular stenting in descending aorta was done in 10 cases (29%); (2) endovascular stenting in descending aorta with fenestrated endograft was done in 8 cases (24%) including fenestration for left subclavian artery in 7 cases and fenestration for left common carotid artery and left subclavian artery in 1 case; (3) endovascular stenting in ascending aorta and arch with fenestrated endograft (fenestration for left subclavian artery and left common carotid artery as well as right brachiocephalic artery) was done in 16 cases (47%). According to with or without pericardial effusion, pericardial drainage or pericardial window operation through left thoracotomy was done in 9 cases (26%). No in-hospital death was noted. Perioperative morbidity was 6% (2/34 cases). One-year survival rate was 100%. And computed tomography angiography follow-up at 6 months and 1 year showed partial absorption of hematoma, no endoleak or new onset of PAU after endovascular repair.
TAIMH is still a life-threatening disease, and TEVAR is safe and efficient, however, further large-scale follow-up studies are required to verify its long-term efficacy.