Clinical efficacy of single branch stent-graft treatment for retrograde type A intramural hematoma_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHEN Bailang , WANG Zanxin , ZHUANG Xianmian , LIU Haibing , CHEN Yao , ZHANG Rui ,  WEI Minxin

Department of Cardiovascular Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, 518053, Guangdong, P.R. China;

Corresponding author：

WEI Minxin, Email: weimx@hku-szh.org

Keywords：

retrograde type A intramural hematoma; single branch stent-graft; Castor; thoracic endovascular aortic repair

DOI：

10.7507/1007-4848.202305049

Video：

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Objective To explore the efficacy of using a single branch stent-graft to treat primary intramural hematoma located at the distal arch or descending aorta in Stanford A type aortic intramural hematoma. Methods From July 2020 to November 2022, 10 patients with primary intramural hematoma of Stanford A type aortic intramural hematoma were treated with endovascular repair using a single branch stent-graft in the Department of Cardiovascular Surgery at The University of Hong Kong-Shenzhen Hospital. There were 9 males and 1 female, aged from 32 to 66 years, with a mean age of (47±10.4) years. All patients had intramural hematoma involving the ascending aorta and aortic arch, diagnosed as type A intramural hematoma, with the tear located in the descending aorta. Among them, 6 patients were complicated by ulceration of the descending aorta with intramural hematoma, and 4 patients had changes of the descending aortic dissection. All patients underwent endovascular stent repair, with 8 patients undergoing emergency surgery (≤14 days) and 2 patients undergoing subacute surgery (15 days to 3 months). Results There were no neurological complications, paraplegia, stent fracture or displacement, or limb or visceral ischemia during the perioperative period in all patients. One patient had continuous chest pain after surgery, and the stent had a new tear at the proximal end, requiring ascending aorta and partial arch replacement. As of the latest follow-up, all patients had obvious absorption or complete absorption of the intramural hematoma in the ascending aorta and aortic arch compared with before the operation. Conclusion Single branch stent-graft treatment of retrograde ascending aortic intramural hematoma is safe and effective, with good short-term results.

1.	Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Kardiol Pol, 2014, 72(12): 1169-2252.
2.	Chen YY, Yen HT, Wu CC, et al. Thoracic endovascular aortic repair for type A intramural hematoma and retrograde thrombosed type A aortic dissection: a single-center experience. Ann Vasc Surg, 2020, 65: 224-231.
3.	Nauta F, de Beaufort H, Mussa FF, et al. Management of retrograde type A IMH with acute arch tear/type B dissection. Ann Cardiothorac Surg, 2019, 8(5): 531-539.
4.	Ferrera C, Vilacosta I, Cabeza B, et al. Diagnosing aortic intramural hematoma: Current perspectives. Vasc Health Risk Manag, 2020, 16: 203-213.
5.	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.
6.	朱健, 郗二平, 朱水波, 等. 腔内修复术治疗破口位于降主动脉合并逆撕性壁间血肿的主动脉夹层. 中华血管外科杂志, 2016, 1(2): 93-96.
7.	杨珏, 于长江, 李欣, 等. 内科与外科治疗急性A型主动脉壁间血肿的回顾性队列研究. 中国胸心血管外科临床杂志, 2023, 30(5): 718-723.
8.	Pape LA, Awais M, Woznicki EM, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17 year trends from the International Registry of Acute Aortic Dissection. J Am Coll Cardiol, 2015, 66(4): 350-358.
9.	Kato N, Hirano T, Shimono T, et al. Treatment of chronic aortic dissection by transluminal endovascular stent-graft placement: preliminary results. J Vasc Interv Radiol, 2001, 12(7): 835-840.
10.	Yang KJ, Chi NH, Yu HY, et al. Outcome comparison between open and endovascular aortic repair for retrograde type A intramural hematoma with intimal tear in the descending thoracic aorta: A retrospective observational study. Front Cardiovasc Med, 2021, 8: 755214.
11.	Song S, Wang Y, Zheng C, et al. Endovascular stent graft treatment of Stanford type B aortic dissection with retrograde type A intramural haematoma: a multicentre retrospective study. Eur J Vasc Endovasc Surg, 2021, 62(1): 140-141.
12.	Li YL, Ye JC, Yancu H, et al. Thoracic endovascular aortic repair for type B aortic dissection associated with retrograde type A intramural hematoma. J Vasc Interv Radiol, 2020, 31(8): 1334-1341.
13.	Shu C, Fan B, Luo M, et al. Endovascular treatment for aortic arch pathologies: chimney, on-the-table fenestration, and in-situ fenestration techniques. J Thorac Dis, 2020, 12(4): 1437-1448.
14.	Ding H, Liu Y , Xie N, et al. Outcomes of chimney technique for preservation of the left subclavian artery in type B aortic dissection. Eur J Vasc Endovasc Surg, 2019, 57(3): 374-381.
15.	Kuo EC, Veranyan N, Johnson CE, et al. Impact of proximal seal zone length and intramural hematoma on clinical outcomes and aortic remodeling after thoracic endovascular aortic repair for aortic dissections. J Vasc Surg, 2019, 69(4): 987-995.
16.	Chen D, Luo M, Fang K, et al. Endovascular repair of acute zone 0 intramural hematoma with most proximal tear or ulcer-like projection in the descending aorta. J Vasc Surg, 2022, 75(5): 1561-1569.
17.	Yammine H, Briggs CS, Stanley GA, et al. Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection. J Vasc Surg, 2019, 69(1): 24-33.
18.	Patterson B, Holt P, Nienaber C, et al. Management of the left subclavian artery and neurologic complications after thoracic endovascular aortic repair. J Vasc Surg, 2014, 60(6): 1491-1497.
19.	Bianco V, Sultan I, Kilic A, et al. Concomitant left subclavian artery revascularization with carotid-subclavian transposition during zone 2 thoracic endovascular aortic repair. J Thorac Cardiovasc Surg, 2020, 159(4): 1222-1227.
20.	Kitamura T, Torii S, Miyamoto T, et al. Watch-and wait strategy for type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta: A Japanese single-centre experience. Eur J Cardiothorac Surg, 2020, 58(3): 590-597.
21.	Sadamatsu K, Takase S, Sagara S, et al. Initial medical management in acute type A aortic dissection patients with a thrombosed false lumen in the ascending aorta combining intramural hematoma and retrograde dissection from the descending to the ascending aorta. Eur Heart J Acute Cardiovasc Care, 2020, 9(3_suppl): S13-S20.
22.	Desai ND, Gottret JP, Szeto WY, et al. Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection. J Thorac Cardiovasc Surg, 2015, 149(2 Suppl): S151-S156.
23.	Li J, Zhang X, Peng Y, et al. Endovascular repair for retrograde type A intramural hematoma with focal intimal disruption in descending aorta. J Thorac Dis, 2021, 13(7): 4250-4259.

1. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Kardiol Pol, 2014, 72(12): 1169-2252.
2. Chen YY, Yen HT, Wu CC, et al. Thoracic endovascular aortic repair for type A intramural hematoma and retrograde thrombosed type A aortic dissection: a single-center experience. Ann Vasc Surg, 2020, 65: 224-231.
3. Nauta F, de Beaufort H, Mussa FF, et al. Management of retrograde type A IMH with acute arch tear/type B dissection. Ann Cardiothorac Surg, 2019, 8(5): 531-539.
4. Ferrera C, Vilacosta I, Cabeza B, et al. Diagnosing aortic intramural hematoma: Current perspectives. Vasc Health Risk Manag, 2020, 16: 203-213.
5. 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.
6. 朱健, 郗二平, 朱水波, 等. 腔内修复术治疗破口位于降主动脉合并逆撕性壁间血肿的主动脉夹层. 中华血管外科杂志, 2016, 1(2): 93-96.
7. 杨珏, 于长江, 李欣, 等. 内科与外科治疗急性A型主动脉壁间血肿的回顾性队列研究. 中国胸心血管外科临床杂志, 2023, 30(5): 718-723.
8. Pape LA, Awais M, Woznicki EM, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17 year trends from the International Registry of Acute Aortic Dissection. J Am Coll Cardiol, 2015, 66(4): 350-358.
9. Kato N, Hirano T, Shimono T, et al. Treatment of chronic aortic dissection by transluminal endovascular stent-graft placement: preliminary results. J Vasc Interv Radiol, 2001, 12(7): 835-840.
10. Yang KJ, Chi NH, Yu HY, et al. Outcome comparison between open and endovascular aortic repair for retrograde type A intramural hematoma with intimal tear in the descending thoracic aorta: A retrospective observational study. Front Cardiovasc Med, 2021, 8: 755214.
11. Song S, Wang Y, Zheng C, et al. Endovascular stent graft treatment of Stanford type B aortic dissection with retrograde type A intramural haematoma: a multicentre retrospective study. Eur J Vasc Endovasc Surg, 2021, 62(1): 140-141.
12. Li YL, Ye JC, Yancu H, et al. Thoracic endovascular aortic repair for type B aortic dissection associated with retrograde type A intramural hematoma. J Vasc Interv Radiol, 2020, 31(8): 1334-1341.
13. Shu C, Fan B, Luo M, et al. Endovascular treatment for aortic arch pathologies: chimney, on-the-table fenestration, and in-situ fenestration techniques. J Thorac Dis, 2020, 12(4): 1437-1448.
14. Ding H, Liu Y , Xie N, et al. Outcomes of chimney technique for preservation of the left subclavian artery in type B aortic dissection. Eur J Vasc Endovasc Surg, 2019, 57(3): 374-381.
15. Kuo EC, Veranyan N, Johnson CE, et al. Impact of proximal seal zone length and intramural hematoma on clinical outcomes and aortic remodeling after thoracic endovascular aortic repair for aortic dissections. J Vasc Surg, 2019, 69(4): 987-995.
16. Chen D, Luo M, Fang K, et al. Endovascular repair of acute zone 0 intramural hematoma with most proximal tear or ulcer-like projection in the descending aorta. J Vasc Surg, 2022, 75(5): 1561-1569.
17. Yammine H, Briggs CS, Stanley GA, et al. Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection. J Vasc Surg, 2019, 69(1): 24-33.
18. Patterson B, Holt P, Nienaber C, et al. Management of the left subclavian artery and neurologic complications after thoracic endovascular aortic repair. J Vasc Surg, 2014, 60(6): 1491-1497.
19. Bianco V, Sultan I, Kilic A, et al. Concomitant left subclavian artery revascularization with carotid-subclavian transposition during zone 2 thoracic endovascular aortic repair. J Thorac Cardiovasc Surg, 2020, 159(4): 1222-1227.
20. Kitamura T, Torii S, Miyamoto T, et al. Watch-and wait strategy for type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta: A Japanese single-centre experience. Eur J Cardiothorac Surg, 2020, 58(3): 590-597.
21. Sadamatsu K, Takase S, Sagara S, et al. Initial medical management in acute type A aortic dissection patients with a thrombosed false lumen in the ascending aorta combining intramural hematoma and retrograde dissection from the descending to the ascending aorta. Eur Heart J Acute Cardiovasc Care, 2020, 9(3_suppl): S13-S20.
22. Desai ND, Gottret JP, Szeto WY, et al. Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection. J Thorac Cardiovasc Surg, 2015, 149(2 Suppl): S151-S156.
23. Li J, Zhang X, Peng Y, et al. Endovascular repair for retrograde type A intramural hematoma with focal intimal disruption in descending aorta. J Thorac Dis, 2021, 13(7): 4250-4259.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesClinical efficacy of single branch stent-graft treatment for retrograde type A intramural hematoma

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