Surgical versus conservative treatment for acute type A aortic intramural hematoma: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

YANG Jue , YU Changjiang , LI Xin , CHEN Zerui , XIAO Fei , SUN Tucheng ,  FAN Ruixin

Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510080, P. R. China;

Corresponding author：

FAN Ruixin, Email: fanruixin@163.com

Keywords：

Aortic intramural hematoma; therapeutic strategy; surgical treatment; conservative treatment

DOI：

10.7507/1007-4848.202103136

Video：

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Objective To compare the outcomes following emergency surgery or conservative treatment for patients with acute type A aortic intramural hematoma (IMH).Methods Clinical data of consecutive patients diagnosed with acute type A aortic IMH in our hospital from September 2014 to December 2018 were retrospectively analyzed. The patients who met our surgical indications received surgery (an operation group) and other patients received strict conservative treatment (a conservative treatment group).Results Finally 127 patients were enrolled, including 112 males and 15 females with an average age of 53.6±13.0 years. Of 127 patients, 85 (66.9%) patients accepted emergency surgery and 42 (33.1%) patients accepted strict conservative treatment. There was no difference between the two groups in early mortality or complications (P＞0.05). The 5-year survival rate was 90.4% in the operation group and 74.3% in the conservative treatment group (P=0.010). A maximum aortic diameter in the ascending aorta and aortic arch≥45 mm and maximum thickness of IMH in the same section≥8 mm were risk factors for IMH-related death in patients undergoing conservative treatment (P＜0.001).Conclusion The mortality associated with emergency surgery for patients with acute type A aortic IMH is satisfactory. In clinical centers with well-established surgical techniques and postoperative management, emergency surgical treatment may provide a better outcome than conservative treatment for patients with acute type A aortic IMH.

Citation： YANG Jue, YU Changjiang, LI Xin, CHEN Zerui, XIAO Fei, SUN Tucheng, FAN Ruixin. Surgical versus conservative treatment for acute type A aortic intramural hematoma: A retrospective cohort study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(5): 718-723. doi: 10.7507/1007-4848.202103136 Copy

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2.	Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(41): 2873-2926.
3.	Song JK. Update in acute aortic syndrome: Intramural hematoma and incomplete dissection as new disease entities. J Cardiol, 2014, 64(3): 153-161.
4.	Maslow A, Atalay MK, Sodha N. Intramural hematoma. J Cardiothorac Vasc Anesth, 2018, 32(3): 1341-1362.
5.	Weiss S, Sen I, Huang Y, et al. Population-based assessment of aortic-related outcomes in aortic dissection, intramural hematoma, and penetrating aortic ulcer. Ann Vasc Surg, 2020, 69: 62-73.
6.	Pelzel JM, Braverman AC, Hirsch AT, et al. International heterogeneity in diagnostic frequency and clinical outcomes of ascending aortic intramural hematoma. J Am Soc Echocardiogr, 2007, 20(11): 1260-1268.
7.	Evangelista A, Mukherjee D, Mehta RH, et al. Acute intramural hematoma of the aorta: A mystery in evolution. Circulation, 2005, 111(8): 1063-1070.
8.	Kitai T, Kaji S, Yamamuro A, et al. Clinical outcomes of medical therapy and timely operation in initially diagnosed type A aortic intramural hematoma: A 20-year experience. Circulation, 2009, 120(11 Suppl): S292-S298.
9.	Song JK, Yim JH, Ahn JM, et al. Outcomes of patients with acute type A aortic intramural hematoma. Circulation, 2009, 120(21): 2046-2052.
10.	Harris KM, Braverman AC, Eagle KA, et al. Acute aortic intramural hematoma: An analysis from the International Registry of Acute Aortic Dissection. Circulation, 2012, 126(11 Suppl 1): S91-S96.
11.	Ferrera C, Vilacosta I, Cabeza B, et al. Diagnosing aortic intramural hematoma: Current perspectives. Vasc Health Risk Manag, 2020, 16: 203-213.
12.	Moral S, Ballesteros E, Evangelista A. Conservative vs surgical treatment in type A intramural hematoma. What is new? J Card Surg, 2020, 35(8): 1758-1760.
13.	Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation, 2010, 121(13): e266-e369.
14.	JCS Joint Working Group. Guidelines for diagnosis and treatment of aortic aneurysm and aortic dissection (JCS 2011): Digest version. Circ J, 2013, 77(3): 789-828.
15.	Kaji S, Akasaka T, Horibata Y, et al. Long term prognosis of patients with type A aortic intramural hematoma. Circulation, 2002, 106(12 Suppl 1): I248-I252.
16.	Moizumi Y, Komatsu T, Motoyoshi N, et al. Management of patients with intramural hematoma involving the ascending aorta. J Thorac Cardiovasc Surg, 2002, 124(5): 918-924.
17.	Evangelista A, Dominguez R, Sebastia C, et al. Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma. Therapeutic implications. Eur Heart J, 2004, 25(1): 81-87.
18.	Mussa FF, Horton JD, Moridzadeh R, et al. Acute aortic dissection and intramural hematoma: A systematic review. JAMA, 2016, 316(7): 754-763.
19.	Song JM, Kim HS, Song JK, et al. Usefulness of the initial noninvasive imaging study to predict the adverse outcomes in the medical treatment of acute type A aortic intramural hematoma. Circulation, 2003, 108 Suppl 1: Ⅱ324-Ⅱ328.
20.	Ferrera C, Vilacosta I, Gómez-Polo JC, et al. Evolution and prognosis of intramural aortic hematoma. Insights from a midterm cohort study. Int J Cardiol, 2017, 249: 410-413.
21.	Hata M, Hata H, Sezai A, et al. Optimal treatment strategy for type A acute aortic dissection with intramural hematoma. J Thorac Cardiovasc Surg, 2014, 147(1): 307-311.
22.	Zhou X, Krishnan A, Hsu J, et al. Delayed surgical management of type A intramural hematoma is not associated with worse outcomes than emergent operation. Heart Surg Forum, 2019, 22(2): E103-E106.
23.	Niino T, Hata M, Sezai A, et al. Optimal clinical pathway for the patient with type B acute aortic dissection. Circ J, 2009, 73(2): 264-268.
24.	Chen Q, Jiang D, Kuang F, et al. Outcomes of type A intramural hematoma: Influence of diabetes mellitus. J Card Surg, 2020, 35(8): 1811-1821.

1. Wang TC, Kuo CL. Aortic intramural hematoma, Stanford type A. J Emerg Med, 2017, 53(6): e137-e138.
2. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(41): 2873-2926.
3. Song JK. Update in acute aortic syndrome: Intramural hematoma and incomplete dissection as new disease entities. J Cardiol, 2014, 64(3): 153-161.
4. Maslow A, Atalay MK, Sodha N. Intramural hematoma. J Cardiothorac Vasc Anesth, 2018, 32(3): 1341-1362.
5. Weiss S, Sen I, Huang Y, et al. Population-based assessment of aortic-related outcomes in aortic dissection, intramural hematoma, and penetrating aortic ulcer. Ann Vasc Surg, 2020, 69: 62-73.
6. Pelzel JM, Braverman AC, Hirsch AT, et al. International heterogeneity in diagnostic frequency and clinical outcomes of ascending aortic intramural hematoma. J Am Soc Echocardiogr, 2007, 20(11): 1260-1268.
7. Evangelista A, Mukherjee D, Mehta RH, et al. Acute intramural hematoma of the aorta: A mystery in evolution. Circulation, 2005, 111(8): 1063-1070.
8. Kitai T, Kaji S, Yamamuro A, et al. Clinical outcomes of medical therapy and timely operation in initially diagnosed type A aortic intramural hematoma: A 20-year experience. Circulation, 2009, 120(11 Suppl): S292-S298.
9. Song JK, Yim JH, Ahn JM, et al. Outcomes of patients with acute type A aortic intramural hematoma. Circulation, 2009, 120(21): 2046-2052.
10. Harris KM, Braverman AC, Eagle KA, et al. Acute aortic intramural hematoma: An analysis from the International Registry of Acute Aortic Dissection. Circulation, 2012, 126(11 Suppl 1): S91-S96.
11. Ferrera C, Vilacosta I, Cabeza B, et al. Diagnosing aortic intramural hematoma: Current perspectives. Vasc Health Risk Manag, 2020, 16: 203-213.
12. Moral S, Ballesteros E, Evangelista A. Conservative vs surgical treatment in type A intramural hematoma. What is new? J Card Surg, 2020, 35(8): 1758-1760.
13. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation, 2010, 121(13): e266-e369.
14. JCS Joint Working Group. Guidelines for diagnosis and treatment of aortic aneurysm and aortic dissection (JCS 2011): Digest version. Circ J, 2013, 77(3): 789-828.
15. Kaji S, Akasaka T, Horibata Y, et al. Long term prognosis of patients with type A aortic intramural hematoma. Circulation, 2002, 106(12 Suppl 1): I248-I252.
16. Moizumi Y, Komatsu T, Motoyoshi N, et al. Management of patients with intramural hematoma involving the ascending aorta. J Thorac Cardiovasc Surg, 2002, 124(5): 918-924.
17. Evangelista A, Dominguez R, Sebastia C, et al. Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma. Therapeutic implications. Eur Heart J, 2004, 25(1): 81-87.
18. Mussa FF, Horton JD, Moridzadeh R, et al. Acute aortic dissection and intramural hematoma: A systematic review. JAMA, 2016, 316(7): 754-763.
19. Song JM, Kim HS, Song JK, et al. Usefulness of the initial noninvasive imaging study to predict the adverse outcomes in the medical treatment of acute type A aortic intramural hematoma. Circulation, 2003, 108 Suppl 1: Ⅱ324-Ⅱ328.
20. Ferrera C, Vilacosta I, Gómez-Polo JC, et al. Evolution and prognosis of intramural aortic hematoma. Insights from a midterm cohort study. Int J Cardiol, 2017, 249: 410-413.
21. Hata M, Hata H, Sezai A, et al. Optimal treatment strategy for type A acute aortic dissection with intramural hematoma. J Thorac Cardiovasc Surg, 2014, 147(1): 307-311.
22. Zhou X, Krishnan A, Hsu J, et al. Delayed surgical management of type A intramural hematoma is not associated with worse outcomes than emergent operation. Heart Surg Forum, 2019, 22(2): E103-E106.
23. Niino T, Hata M, Sezai A, et al. Optimal clinical pathway for the patient with type B acute aortic dissection. Circ J, 2009, 73(2): 264-268.
24. Chen Q, Jiang D, Kuang F, et al. Outcomes of type A intramural hematoma: Influence of diabetes mellitus. J Card Surg, 2020, 35(8): 1811-1821.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Surgical versus conservative treatment for acute type A aortic intramural hematoma: A retrospective cohort study

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