- Email: [email protected]
Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single-Center Experience
Journal Pre-proof Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single Center Experience Yen-Yu Chen, Hsu-Ting Yen, Chia-Chen Wu, David Kwan-Ru Huang PII:
S0890-5096(19)30978-1
DOI:
https://doi.org/10.1016/j.avsg.2019.11.016
Reference:
AVSG 4779
To appear in:
Annals of Vascular Surgery
Received Date: 3 October 2019 Revised Date:
10 November 2019
Accepted Date: 11 November 2019
Please cite this article as: Chen YY, Yen HT, Wu CC, Kwan-Ru Huang D, Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single Center Experience, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/ j.avsg.2019.11.016. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single Center Experience
Yen-Yu Chen*, Hsu-Ting Yen, Chia-Chen Wu, David Kwan-Ru Huang
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
*Corresponding author: Dr. Yen-Yu Chen, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123, Ta-Pei Road, NiaoSung, Kaohsiung City 83301, Taiwan E-mail: [email protected] Tel: +886-7-7317123 ext. 8008 Fax: +886-7-7354309
1
1
Abstract
2
Objective: The aim of this study was to present our experience of thoracic endovascular aortic repair (TEVAR)
3
for type A intramural hematoma (TAIMH) and retrograde thrombosed type A aortic dissection (rt-TAAD) with the
4
entry tear in the descending aorta or the abdominal aorta and discuss the outcomes.
5
Material and Methods: We retrospective reviewed total 6 patients who underwent TEVAR for TAIMH (n = 2) or
6
rt-TAAD (n = 4) in our hospital between September 2017 and July 2019. The mean age of the patients (5 men and
7
1 woman) was 74 ± 13 years, and the mean follow-up duration was 13 ± 7 months.
8
Results: TEVAR was successfully performed in the acute phase in all patients without relevant complications.
9
After TEVAR, the shrinkage of enlarged thoracic aorta and complete resorptions of the false lumen of the entire
10
thoracic aorta were achieved in 4 patients. In the remaining 2 patients, one had residual thrombosed false lumen of
11
the ascending aorta due to a new development of PAU at the distal aortic arch and another need additional
12
endovascular intervention for ascending aorta hematoma progression. Late aorta-related adverse event was
13
observed in 1 patient, who needed open aortic repair. There was no death during follow-up.
14
Conclusions: Tear-oriented endovascular aortic repair is a potential option in selected patients of TAIMH and
15
rt-TAAD and has shown favorable immediate outcomes and aortic remodeling. However, the late aorta-related
16
adverse event is not negligible, and their long-term outcome has not been fully clarified. More research is
17
warranted.
18 19
Keywords: Type A intramural hematoma; Retrograde type A aortic dissection; Thoracic endovascular aortic
20
repair. 2
21
INTRODUCTION
22
Acute aortic syndrome is one of the most lethal aortic disorders, including classic aortic dissection, intramural
23
hematoma (IMH), and penetrating aortic ulcer (PAU) (1). Emergent open aortic repair is required when the
24
ascending aorta is involved, so called Stanford type A acute aortic dissection (TAAD). The entry tear is located in
25
the ascending aorta in most TAAD patients. Retrograde TAAD (r-TAAD) develops in a retrograde fashion with a
26
primary intimal tear located in the descending aorta or the abdominal aorta (2, 3). Although surgical outcomes
27
have improved with developments in surgical instrumentation and techniques, the operative mortality rate still
28
ranges from 18% to 27% (4, 5). For the goal of the exclusion of the primary intimal tear, more extensive distal
29
aortic repair with replacement of the ascending aorta, aortic arch and frozen elephant technique have been
30
advocated, and it may increase in-hospital mortality (6, 7). In contrast to the antegrade TAAD, the most
31
appropriate management for r-TAAD is controversial (2).
32
IMH, a subtype of acute aortic syndrome, is defined as acute aortic dissection with no visible intimal tear or
33
flap (1). It is characterized by the presence of a hematoma within the aortic wall and is recognizable as a crescent
34
or circular local aortic wall thickening. The mechanism of IMH is believed to result from the rupture of vasa
35
vasorum and possible small PAUs (8). The treatment strategy for type A IMH (TAIMH) may depend on clinical
36
presentations and radiographic findings (9, 10).
37
Recently, thoracic endovascular aortic repair (TEVAR) had been used for r-TAAD for entry tear closure
38
(11-13). Plaque rupture or small intimomedial tears may be identified in some subgroup IMH patients could
39
benefit from endovascular stent graft placement (14, 15). However, the efficacy of TEVAR for TAIMH and
40
r-TAAD is not yet established. The aim of this study was to describe our experience with endovascular repair for 3
41
TAAD with an entry tear in the descending thoracic aorta or the abdominal aorta.
42 43
MATERIAL AND METHODS
44
Study Design and Patient Selection
45
From September 2017 to July 2019, there were 68 symptomatic patients with Stanford type A acute aortic
46
dissection were treated surgically at our hospital, and all diagnoses were confirmed by contrast-enhanced
47
multidetector-row computed tomography. Classic TAAD was defined as a double channel aorta with a visible
48
intimal flap and patent false lumen in the ascending aorta. R-TAAD was defined as ascending aortic dissection
49
developed in a retrograde fashion with a primary intimal tear located in the descending aorta or the abdominal
50
aorta, and the false lumen in the ascending aorta had partial or complete thrombosis. TAIMH was defined as the
51
presence of a hematoma within the ascending aortic wall and is recognizable as a crescent or circular local aortic
52
wall thickening without visible intimal flap. As a result, open aortic repair was performed in 46 patients with
53
classic TAAD, 7 patients with r-TAAD and 9 patients with TAIMH. The in-hospital mortality of patients receiving
54
open aortic repair was 21%. TEVAR was chosen for the remaining 6 patients who met these criteria: (1) R-TAAD
55
and the false lumen of the ascending aorta was completely thrombosed (rt-TAAD); (2) TAIMH with one or more
56
focal calcified intima disruption, contrast-material filled, craterlike outpouchings of the aortic lumen in the
57
descending thoracic aorta; (3) A distance between the left subclavian artery and the nearest entry tear or PAU of at
58
least 0.5 cm; (4) No signs of cardiac tamponade or severe aortic regurgitation (grade III or IV); (5) No signs of
59
ischemia of the coronary artery or aortic arch branches; and (6) The sufficiently large femoral and iliac arteries to
60
allow insertion of the delivery system. TEVAR was performed in the hyperacute phase in 4 patients (within 24 4
61
hours of presentation of symptoms) and in the acute phase in 2 patients (1-14 days). The mean interval between
62
diagnosis and TEVAR was 2.0 ± 3.6 days (range, 0-9 days). The indications for TEVAR were TAIMH with PAU
63
(n = 2), ascending aorta hematoma progression (n = 1), persistent back pain with imaging evidence of left kidney
64
malperfusion (n = 1), and maximum ascending aortic hematoma thickness of ≥ 11mm (n = 2). The medical
65
records and computed tomography (CT) imaging appearances of these 6 patients were retrospectively reviewed to
66
investigate clinical and imaging outcome. This retrospective study was approved by the Institutional Review
67
Board of Kaohsiung Chang Gung Memorial Hospital and a waiver of the need to obtain consent from patients was
68
approved because of the study’s retrospective design.
69 70
Operative Details and Device Selection
71
All TEVARs were performed in the hybrid operating room (Siemens Artis zeego multi-axis system). TEVAR was
72
performed under general anesthesia and the common femoral artery access was chosen in all patients. A 6F
73
introducer sheath was inserted into the common femoral artery using the Seldinger technique, and a 5F sizing
74
pigtail catheter was advanced through the sheath into the ascending aorta via a 0.035-inch wire to perform
75
aortograms. For wiring into true lumen of the aorta, repeat angiography with one or two bolus of contrast injection
76
would be performed if necessary. Intravascular ultrasound was not used in all patients. The location of the
77
supra-aortic branches as well as the entry site or PAU was identified. After systemic heparinization therapy with
78
100IU/kg, the stent graft was then advanced into the aorta and deployed using the extra-stiff wire (Cook, Inc)
79
during systemic hypotension with a systolic pressure of 60mmHg to 80 mmHg by using inhalation anesthestic
80
(sevoflurane), intravenous beta-blockers (labetalol) or intravenous calcium channel blockers (nicardipine). At the 5
81
proximal landing zones, Zone 3 TEVAR with or without partial coverage of the left subclavian artery were
82
performed in 5 patients and Zone 2 TEVAR with the chimney technique for preserving the left subclavian artery
83
was performed in 1 patient. The distal end of the stent graft device was placed at the mid descending aorta above
84
the T8 level. Two different, commercially available stent graft systems were used. The Medtronic Valiant thoracic
85
endovascular stent graft (Medtronic, Inc, Minneapolis, MN, USA) was used in 1 patient. The Conformable Gore
86
TAG (CTAG) device (W. L. Gore & Associates, Inc, Flagstaff, AZ, USA) were used in 5 patients.
87 88
Radiologic Measurements
89
All CT images were performed on a 64/128–slice multidetector CT scanner with 3-phase (non-contrast, arterial,
90
and delayed phases) technique and images were reconstructed with a section thickness of 0.625mm without using
91
the electrocardiographic-gating. The maximal aortic diameter, the false lumen thickness, and hematoma thickness
92
were measured at the ascending aorta at near the level of the left or right main pulmonary artery. The diameter of
93
the stent graft was determined by the aortic diameter of the proximal and distal landing zone as measured on CT
94
images. A device with a diameter equal to or smaller than the aortic diameter but larger than the diameter of the
95
true lumen was selected. The true lumen diameter was calculated as the mean value of the longer and the shorter
96
diameter of the true lumen. All changes in CT imaging appearance during follow-up were recorded. Hematoma
97
regression was defined as the decreased maximum hematoma thickness ≥ 3mm. Hematoma progression was
98
defined as the increased maximum hematoma thickness ≥ 3mm. Complete resorption was defined as remaining
99
hematoma thickness ≤ 3mm.
100 6
101
Study Endpoint
102
The primary end point was death from all causes and the secondary end points were all adverse events related to
103
the aortic dissection and TEVAR, including aortic rupture, cardiac tamponade, hematoma progression need
104
reintervention, evolution to classic type A aortic dissection, new development of PAU, IMH, or classic aortic
105
dissection, PAU enlargement, and endoleak. Early aorta-related adverse event was defined as an aortic event
106
related to the aortic dissection and TEVAR within 3 months after TEVAR. Late aorta-related adverse event was
107
defined as an aortic event beyond 3 months after TEVAR.
108 109
Follow-up
110
In the study, 100% follow-up rates were achieved by the means of either a clinic follow-up or telephone contact.
111
For all patients, follow-up CT images were obtained within 3 months after TEVAR and annually thereafter. The
112
mean follow-up duration was 12.8 ± 6.9 months (range, 6-22 months).
113 114
RESULTS
115
Clinical Outcomes
116
The surgical techniques and clinical outcomes were summarized in Table 1. All patients survived surgery and
117
stent graft placement was successful in all patients. No relevant dissection, aortic rupture, neurological defect,
118
malperfusion of aortic branches, access site complication, spinal cord ischemia or endoleak was noted after
119
TEVAR. After discharge, there were three aorta-related adverse events (case 2, 5, 6). One patient (case 2) was
120
noted to have a new development of PAU at the distal aortic arch accidentally on the follow-up CT imaging, and 7
121
treated conservatively in the outpatient clinic. One patient (case 5) presented with ascending aorta hematoma
122
progression at 6-week CT follow-up after TEVAR and needed candy-plug deployment of the false lumen of the
123
descending aorta for occlusion of retrograde flow through the distal re-entry tear at the level of celiac trunk
124
(Figure 1). One patient (case 6) had developed symptomatic TAAD with a new intimal tear in the ascending aorta
125
4 months after TEVAR, although complete resorption of the false lumen after initial TEVAR was achieved (Figure
126
2). He finally underwent open aortic repair and was still alive.
127 128
Aortic Remodeling
129
The characteristics of aortic dissection and results of aortic remodeling were summarized in Table 2. After
130
TEVAR and re-TEVAR, the shrinkage of enlarged thoracic aorta and complete resorptions of the false lumen of
131
the entire thoracic aorta were observed in 5 patients, and hematoma regression was observed in 1 patient (case 2).
132
The preoperative and postoperative mean maximum aortic diameter of the ascending aorta was 46 ± 5 mm (range,
133
39-52 mm) and 43 ± 5 mm (range 35-48 mm), respectively. The stent graft was oversized to the aortic diameter at
134
the proximal and the distal landing zones by -12% ± 7% (-26% to -5%) and -3% ± 6% (-9% to 0%), respectively.
135
The stent graft was oversized to the true lumen at the proximal and the distal landing zones by 25% ± 22% (8% to
136
68%) and 14% ± 10% (3% to 30%), respectively.
137 138
DISCUSSION
139
Of all TAADs, TAIMH accounted for 22% to 28% in the East Asian studies (9, 16), and r-TAAD accounted for
140
9% to 25% of TAAD (2, 3). In our study, TAIMH and r-TAAD respectively accounted for 16% and 16% in 8
141
surgically treated TAAD patients. TAIMH has a variable course, and aortic diameter ≥ 50mm, hematoma
142
thickness ≥ 11mm, and presence of PAU are supposed to predict worse outcome (9, 10, 17, 18), that open aortic
143
repair is recommended. However, 20% TAIMH patients had PAU in the distal aortic arch or the descending aorta
144
that cannot be treated with ascending aorta and hemiarch replacement alone (19, 20). Besides, PAU enlargement
145
is common, and it is a risk factor of late aortic event if untreated (20). Grimm et al (14) successfully used stent
146
grafts to treat 8 IMH patients with plaque rupture in the distal arch to the descending aorta. Complete remodeling
147
of the entire thoracic aorta was observed in 6 patients, and classic type B aortic dissection distal to the stent graft
148
was observed in the remaining 2 patients. In our study, favorable aortic remodeling could be achieved in our 2
149
TAIMH patients without visible graft-induced intimal injury.
150
TEVAR for r-TAAD was accepted as an alternative management strategy in highly selected patients (11, 12,
151
21). The previous studies showed favorable short-term results and good remodeling of the affected aorta after
152
TEVAR, which were summarized in Table 3. However, the excellent results could not be obtained in a larger
153
series of 31 patients (22). Higashigawa et al (22) reported early aorta-related adverse events were observed in 8
154
patients (26%), including in-hospital mortality in 1 patient, the need for open aortic repair for unresolved endoleak
155
in 2 patients, and requiring additional intervention in 3 patients. At a mean follow-up of 99 months, late
156
aorta-related adverse events were observed in 7 patients (23%), including new TAAD in 3 patients, and persistent
157
endoleak in 2 patients. In our study, additional endovascular intervention for re-entry closure was required in 1
158
patient, and new TAAD developed in 1 patient, but no endoleaks were noted.
159 160
Accurate sizing of the stent graft is important to prevent endoleak and graft-induced intimal injury. In general, stent grafts are usually oversized by 5% to 10% relative to the aortic diameter of predicted landing zone and those 9
161
always depend on the aortic morphology of individual patients and surgeon experience. In our study, the stent
162
graft was oversized to the true lumen at the proximal landing zones by 25% ± 22%, less than those (34% ± 29%)
163
in the series of Higashigawa et al (22). Because the true lumen had different degree of compression by the
164
expanded false lumen, the true lumen might not be suitable as reference. So we preferred to select stent graft with
165
a diameter equal to or smaller than the maximum aortic diameter for the purpose of sealing off the entry tear.
166
Following the above principle, the short-term outcome seemed to be acceptable, and there was no graft-induced
167
intimal injury or endoleak in our study.
168
Evaluating patient suitability, using an advanced imaging system to detect the location of entry tear, correct
169
measurement of the aortic diameter, and planning the endovascular intervention are crucial for the success of
170
TEVAR. First, thin-section CT image with multiplanar reconstructive techniques rather than axial images alone
171
should be performed preoperatively for assessment of the extent of the dissection, the determination of the
172
primary entry site, and accurate measurement of the aortic diameter. Second, for adequate proximal and distal
173
landing zones to avoid endoleak, a distance between the landing site and the entry tear of at least 15 mm is
174
recommended. Insufficient landing zones may necessitate partial coverage of the left subclavian artery with or
175
without endo-wedge technique, additional intervention (chimney/periscopic technique, debranching procedure), or
176
use fenestrated stent graft. Coverage of the left subclavian artery was only performed in patients with
177
life-threatening situation and lack of the risks of vertebrobasilar ischemia and spinal cord ischemia. Third, we
178
suggest choosing sufficient conformable stent graft and selecting the size equal to or smaller than the maximum
179
aortic diameter of the landing zone.
180
To date, there is no optimal treatment strategy for r-TAAD. Although TEVAR for highly selective patients 10
181
with r-TAAD showed favorable outcome in some studies (11, 12, 21, 22), open surgical repair is still the gold
182
standard treatment for TAAD. However, for the goal of the entry closure, extended hybrid aortic repair with total
183
arch replacement and frozen elephant trunk technique had to be performed. In our study, among 7 r-TAAD
184
patients who underwent open aortic repair, ascending aorta replacement with or without hemiarch replacement
185
was performed in 2 patients, combined ascending aorta replacement and one-stage or two-stage TEVAR was
186
performed in 3 patients, and hybrid aortic repair with total arch replacement and frozen elephant trunk technique
187
was performed in 2 patients; of those, 2 patients who underwent hybrid aortic repair died of postoperative
188
refractory heart failure and mesenteric ischemia, respectively. Of these 7 patients, follow-up CT revealed
189
complete remodeling of the entire thoracic aorta in patients only when endovascular repair was performed.
190
There are several limitations to our study. First, the limited number of patients and the short duration of
191
follow-up is the most limitation of this study. Second, some patients with thinner IMH (≤ 7mm) of the ascending
192
aorta had also included, that may not be recognized as TAIMH, and was excluded in some studies.
193 194
CONCLUSION
195
Tear-oriented endovascular aortic repair is a potential therapeutic opinion in suitable cases of TAIMH and
196
rt-TAAD with the entry tear in the descending aorta or the abdominal aorta. In highly selected patient, TEVAR has
197
shown favorable short-term outcome and aortic remodeling. However, the late aorta-related adverse event is not
198
negligible, and close follow-up is mandatory. Besides, more research is warranted to provide long-term benefit.
199 200
Funding statement 11
201
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit
202
sectors.
203 204
Conflict of interest statement
205
Conflict of interest: none declared.
206 207
Figure legends
208
Figure 1. A 57-year-old male with retrograde type A aortic dissection. Preoperative CT showed thrombosed FL of
209
the ascending aorta and patent FL of the descending aorta (A). The entry tear (arrow) could be identified in the
210
descending aorta (B). CT image was obtained 6 weeks after TEVAR. The ascending aorta hematoma was still
211
seen (C) and the FL of the descending aorta was partially thrombosed (D). Retrograde flow through the distal
212
re-entry tear was seen on predeployment angiography (E) and was occluded after candy-plug deployment (F).
213
Follow-up CT showed complete resorption of the FL of the entire thoracic aorta (G and H). CT, computed
214
tomography; FL, false lumen; TEVAR, thoracic endovascular aortic repair.
215
Figure 2. A 80-year-old male with retrograde type A aortic dissection. Preoperative CT showed the FL of the
216
ascending aorta and the distal descending aorta was partially thrombosed (A) and an entry tear (arrow) could be
217
identified in the descending aorta (B). Three days later after TEVAR, follow-up CT showed complete resorption
218
of the FL of the entire thoracic aorta (C and D). Four months later, a new intimal tear in the mid ascending aorta
219
was noted on the follow-up CT imaging (E and F). CT, computed tomography; FL, false lumen; TEVAR, thoracic
220
endovascular aortic repair. 12
Reference:
1. 2.
Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation. 2005;112(24):3802-13. Kaji S, Akasaka T, Katayama M, et al. Prognosis of retrograde dissection from the descending to
the ascending aorta. Circulation. 2003;108 Suppl 1:Ii300-6. 3. Kim JB, Choo SJ, Kim WK, et al. Outcomes of acute retrograde type A aortic dissection with an entry tear in descending aorta. Circulation. 2014;130(11 Suppl 1):S39-44. 4. 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. Journal of the American College of Cardiology. 2015;66(4):350-8. 5. Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD). European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2009;37(2):149-59. 6. Cabasa A, Pochettino A. Surgical management and outcomes of type A dissection-the Mayo Clinic experience. Annals of cardiothoracic surgery. 2016;5(4):296-309. 7. Rylski B, Beyersdorf F, Kari FA, et al. Acute type A aortic dissection extending beyond ascending aorta: Limited or extensive distal repair. The Journal of thoracic and cardiovascular surgery. 2014;148(3):949-54; discussion 54. 8. Oderich GS, Karkkainen JM, Reed NR, et al. Penetrating Aortic Ulcer and Intramural Hematoma. Cardiovascular and interventional radiology. 2019;42(3):321-34. 9. 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):S292-8. 10. Kaji S, Nishigami K, Akasaka T, et al. Prediction of progression or regression of type A aortic intramural hematoma by computed tomography. Circulation. 1999;100(19 Suppl):Ii281-6. 11. Kato N, Shimono T, Hirano T, et al. Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta. Journal of vascular surgery. 2001;34(6):1023-8. 12. Shu C, Wang T, Li QM, et al. Thoracic endovascular aortic repair for retrograde type A aortic dissection with an entry tear in the descending aorta. Journal of vascular and interventional radiology : JVIR. 2012;23(4):453-60, 60.e1. 13. Araujo PV, Joviliano EE, Ribeiro MS, et al. Endovascular treatment for acute aortic syndrome. Ann Vasc Surg. 2012;26(4):516-20. 14. Grimm M, Loewe C, Gottardi R, et al. Novel insights into the mechanisms and treatment of intramural hematoma affecting the entire thoracic aorta. The Annals of thoracic surgery. 2008;86(2):453-6. 15. Lavingia KS, Ahanchi SS, Redlinger RE, et al. Aortic remodeling after thoracic endovascular aortic repair for intramural hematoma. Journal of vascular surgery. 2014;60(4):929-35; discussion 35-6. 16. Song JK, Yim JH, Ahn JM, et al. Outcomes of patients with acute type a aortic intramural hematoma. Circulation. 2009;120(21):2046-52. 13
17. 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:Ii324-8. 18. Ganaha F, Miller DC, Sugimoto K, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002;106(3):342-8. 19. Shimokawa T, Ozawa N, Takanashi S, et al. Intermediate-term results of surgical treatment of acute intramural hematoma involving the ascending aorta. The Annals of thoracic surgery. 2008;85(3):982-6. 20. Chen YY, Yen HT, Lo CM, et al. Natural courses and long-term results of type A acute aortic intramural haematoma and retrograde thrombosed type A acute aortic dissection: a single-centre experience. Interactive cardiovascular and thoracic surgery. 2019. 21. Urbanski PP, Sodah A, Matveeva A, et al. Importance of accurately locating the entry site for endovascular treatment of retrograde Type A acute aortic dissection. Interactive cardiovascular and thoracic surgery. 2018;26(5):731-7. 22. Higashigawa T, Kato N, Nakajima K, et al. Thoracic endovascular aortic repair for retrograde type A aortic dissection. Journal of vascular surgery. 2019;69(6):1685-93.
14
Table 1. Clinical Summary of Patients Treated with Endovascular Aortic Repair Case
Age, years
No.
/Sex
1
91/M
TAIMH
PAU at DesAo
27
Zone 2-3
No
6
2
69/F
rt-TAAD
AA
200
Zone 3 + coils/plug embolization
New PAU develop at distal aortic
5
of false lumen (supraceliac level)
arch
AD type
Entry site
Distance between LSC
TEVAR
Aortic events
and entry site, mm
Follow-up (months)
3
63/M
rt-TAAD
DesAo
16
Zone 2-3
No
17
4
83/M
TAIMH
PAU at DesAo
6
Zone 2 + LSC chimney
No
22
5
57/M
rt-TAAD
DesAo
25
Zone 2-3
AsAo hematoma progression need
17
re-TEVAR 6
80/M
rt-TAAD
DesAo
30
Zone 3
New classic type A AD develop
10
AA, abdominal aorta; AD, aortic dissection; AsAo, ascending aorta; DesAo, descending aorta; LSC, left subclavian artery; PAU, penetrating aortic ulcer; rt-TAAD, retrograde thrombosed type A aortic dissection; ; TAMIH, type A intramural hematoma; TEVAR, thoracic endovascular aortic repair.
Table 2. Characteristics of Aortic Dissection and Results of Aortic Remodeling after Initial Endovascular Aortic Repair Case
AsAo diameter, mm
Aortic diameter/true
Device diameter at
Aortic diameter/true
No.
/hematoma thickness, mm
lumen at proximal
proximal landing zone,
lumen at distal landing landing zone, mm
landing zone, mm
mm
zone, mm
Device diameter at distal
Thoracic aortic remodeling
1
50/4
42/37
40
35/30
32
CR
2
46/10
38/25
28
28/22
26
Regression
3
43/4
42/22
37
35/32
34
CR
4
46/6
40/33
37
31/26
31
CR
5
39/17
31/22
28
28/20
26
Progression
6
52/19
35/25
31
33/30
31
CR
AsAo, ascending aorta; CR, complete resorption.
Table 3. Summary of Previous Studies Aortic remodeling (complete TFL) Journal
Kato et al, 2001
N
10
TEVAR
Zone 3 or Zone 4 (n = 10)
(11) Shu et al, 2012
17
5
2018 (20) Our study, 2019
Aortic events
Saccular aneurysm develop below stent graft (n = 1)
follow-up
AsAo
DesAo
100%
100%
20 months
100%
41%
26 months
additional stent graft for re-entry closure (n = 1)
(12) Urbanski et al,
Mean
Zone 2 + LSC coverage (n = 4) New entry tear develop in the distal edge of the stent Zone 3 or Zone 4 (n = 13)
graft (n = 1)
Zone 2 + C-SC bypass (n = 1)
None
100%
100%
28 months
Zone 2 + LSC chimney (n = 1)
New PAU develop at distal aortic arch (n = 1)
100%
100%
13 months
Zone 3 ± embolization of false
New classic type A aortic dissection develop (n =1)
Zone 3 (n = 4) 6
lumen (n = 5) AsAo, ascending aorta; C-SC, carotid-subclavian; DesAo, Descending aorta; LSC, left subclavian artery; PAU, penetrating aortic ulcer; TEVAR, thoracic endovascular aortic repair; TFL, thrombosed false lumen.
S0890-5096(19)30978-1
DOI:
https://doi.org/10.1016/j.avsg.2019.11.016
Reference:
AVSG 4779
To appear in:
Annals of Vascular Surgery
Received Date: 3 October 2019 Revised Date:
10 November 2019
Accepted Date: 11 November 2019
Please cite this article as: Chen YY, Yen HT, Wu CC, Kwan-Ru Huang D, Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single Center Experience, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/ j.avsg.2019.11.016. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single Center Experience
Yen-Yu Chen*, Hsu-Ting Yen, Chia-Chen Wu, David Kwan-Ru Huang
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
*Corresponding author: Dr. Yen-Yu Chen, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123, Ta-Pei Road, NiaoSung, Kaohsiung City 83301, Taiwan E-mail: [email protected] Tel: +886-7-7317123 ext. 8008 Fax: +886-7-7354309
1
1
Abstract
2
Objective: The aim of this study was to present our experience of thoracic endovascular aortic repair (TEVAR)
3
for type A intramural hematoma (TAIMH) and retrograde thrombosed type A aortic dissection (rt-TAAD) with the
4
entry tear in the descending aorta or the abdominal aorta and discuss the outcomes.
5
Material and Methods: We retrospective reviewed total 6 patients who underwent TEVAR for TAIMH (n = 2) or
6
rt-TAAD (n = 4) in our hospital between September 2017 and July 2019. The mean age of the patients (5 men and
7
1 woman) was 74 ± 13 years, and the mean follow-up duration was 13 ± 7 months.
8
Results: TEVAR was successfully performed in the acute phase in all patients without relevant complications.
9
After TEVAR, the shrinkage of enlarged thoracic aorta and complete resorptions of the false lumen of the entire
10
thoracic aorta were achieved in 4 patients. In the remaining 2 patients, one had residual thrombosed false lumen of
11
the ascending aorta due to a new development of PAU at the distal aortic arch and another need additional
12
endovascular intervention for ascending aorta hematoma progression. Late aorta-related adverse event was
13
observed in 1 patient, who needed open aortic repair. There was no death during follow-up.
14
Conclusions: Tear-oriented endovascular aortic repair is a potential option in selected patients of TAIMH and
15
rt-TAAD and has shown favorable immediate outcomes and aortic remodeling. However, the late aorta-related
16
adverse event is not negligible, and their long-term outcome has not been fully clarified. More research is
17
warranted.
18 19
Keywords: Type A intramural hematoma; Retrograde type A aortic dissection; Thoracic endovascular aortic
20
repair. 2
21
INTRODUCTION
22
Acute aortic syndrome is one of the most lethal aortic disorders, including classic aortic dissection, intramural
23
hematoma (IMH), and penetrating aortic ulcer (PAU) (1). Emergent open aortic repair is required when the
24
ascending aorta is involved, so called Stanford type A acute aortic dissection (TAAD). The entry tear is located in
25
the ascending aorta in most TAAD patients. Retrograde TAAD (r-TAAD) develops in a retrograde fashion with a
26
primary intimal tear located in the descending aorta or the abdominal aorta (2, 3). Although surgical outcomes
27
have improved with developments in surgical instrumentation and techniques, the operative mortality rate still
28
ranges from 18% to 27% (4, 5). For the goal of the exclusion of the primary intimal tear, more extensive distal
29
aortic repair with replacement of the ascending aorta, aortic arch and frozen elephant technique have been
30
advocated, and it may increase in-hospital mortality (6, 7). In contrast to the antegrade TAAD, the most
31
appropriate management for r-TAAD is controversial (2).
32
IMH, a subtype of acute aortic syndrome, is defined as acute aortic dissection with no visible intimal tear or
33
flap (1). It is characterized by the presence of a hematoma within the aortic wall and is recognizable as a crescent
34
or circular local aortic wall thickening. The mechanism of IMH is believed to result from the rupture of vasa
35
vasorum and possible small PAUs (8). The treatment strategy for type A IMH (TAIMH) may depend on clinical
36
presentations and radiographic findings (9, 10).
37
Recently, thoracic endovascular aortic repair (TEVAR) had been used for r-TAAD for entry tear closure
38
(11-13). Plaque rupture or small intimomedial tears may be identified in some subgroup IMH patients could
39
benefit from endovascular stent graft placement (14, 15). However, the efficacy of TEVAR for TAIMH and
40
r-TAAD is not yet established. The aim of this study was to describe our experience with endovascular repair for 3
41
TAAD with an entry tear in the descending thoracic aorta or the abdominal aorta.
42 43
MATERIAL AND METHODS
44
Study Design and Patient Selection
45
From September 2017 to July 2019, there were 68 symptomatic patients with Stanford type A acute aortic
46
dissection were treated surgically at our hospital, and all diagnoses were confirmed by contrast-enhanced
47
multidetector-row computed tomography. Classic TAAD was defined as a double channel aorta with a visible
48
intimal flap and patent false lumen in the ascending aorta. R-TAAD was defined as ascending aortic dissection
49
developed in a retrograde fashion with a primary intimal tear located in the descending aorta or the abdominal
50
aorta, and the false lumen in the ascending aorta had partial or complete thrombosis. TAIMH was defined as the
51
presence of a hematoma within the ascending aortic wall and is recognizable as a crescent or circular local aortic
52
wall thickening without visible intimal flap. As a result, open aortic repair was performed in 46 patients with
53
classic TAAD, 7 patients with r-TAAD and 9 patients with TAIMH. The in-hospital mortality of patients receiving
54
open aortic repair was 21%. TEVAR was chosen for the remaining 6 patients who met these criteria: (1) R-TAAD
55
and the false lumen of the ascending aorta was completely thrombosed (rt-TAAD); (2) TAIMH with one or more
56
focal calcified intima disruption, contrast-material filled, craterlike outpouchings of the aortic lumen in the
57
descending thoracic aorta; (3) A distance between the left subclavian artery and the nearest entry tear or PAU of at
58
least 0.5 cm; (4) No signs of cardiac tamponade or severe aortic regurgitation (grade III or IV); (5) No signs of
59
ischemia of the coronary artery or aortic arch branches; and (6) The sufficiently large femoral and iliac arteries to
60
allow insertion of the delivery system. TEVAR was performed in the hyperacute phase in 4 patients (within 24 4
61
hours of presentation of symptoms) and in the acute phase in 2 patients (1-14 days). The mean interval between
62
diagnosis and TEVAR was 2.0 ± 3.6 days (range, 0-9 days). The indications for TEVAR were TAIMH with PAU
63
(n = 2), ascending aorta hematoma progression (n = 1), persistent back pain with imaging evidence of left kidney
64
malperfusion (n = 1), and maximum ascending aortic hematoma thickness of ≥ 11mm (n = 2). The medical
65
records and computed tomography (CT) imaging appearances of these 6 patients were retrospectively reviewed to
66
investigate clinical and imaging outcome. This retrospective study was approved by the Institutional Review
67
Board of Kaohsiung Chang Gung Memorial Hospital and a waiver of the need to obtain consent from patients was
68
approved because of the study’s retrospective design.
69 70
Operative Details and Device Selection
71
All TEVARs were performed in the hybrid operating room (Siemens Artis zeego multi-axis system). TEVAR was
72
performed under general anesthesia and the common femoral artery access was chosen in all patients. A 6F
73
introducer sheath was inserted into the common femoral artery using the Seldinger technique, and a 5F sizing
74
pigtail catheter was advanced through the sheath into the ascending aorta via a 0.035-inch wire to perform
75
aortograms. For wiring into true lumen of the aorta, repeat angiography with one or two bolus of contrast injection
76
would be performed if necessary. Intravascular ultrasound was not used in all patients. The location of the
77
supra-aortic branches as well as the entry site or PAU was identified. After systemic heparinization therapy with
78
100IU/kg, the stent graft was then advanced into the aorta and deployed using the extra-stiff wire (Cook, Inc)
79
during systemic hypotension with a systolic pressure of 60mmHg to 80 mmHg by using inhalation anesthestic
80
(sevoflurane), intravenous beta-blockers (labetalol) or intravenous calcium channel blockers (nicardipine). At the 5
81
proximal landing zones, Zone 3 TEVAR with or without partial coverage of the left subclavian artery were
82
performed in 5 patients and Zone 2 TEVAR with the chimney technique for preserving the left subclavian artery
83
was performed in 1 patient. The distal end of the stent graft device was placed at the mid descending aorta above
84
the T8 level. Two different, commercially available stent graft systems were used. The Medtronic Valiant thoracic
85
endovascular stent graft (Medtronic, Inc, Minneapolis, MN, USA) was used in 1 patient. The Conformable Gore
86
TAG (CTAG) device (W. L. Gore & Associates, Inc, Flagstaff, AZ, USA) were used in 5 patients.
87 88
Radiologic Measurements
89
All CT images were performed on a 64/128–slice multidetector CT scanner with 3-phase (non-contrast, arterial,
90
and delayed phases) technique and images were reconstructed with a section thickness of 0.625mm without using
91
the electrocardiographic-gating. The maximal aortic diameter, the false lumen thickness, and hematoma thickness
92
were measured at the ascending aorta at near the level of the left or right main pulmonary artery. The diameter of
93
the stent graft was determined by the aortic diameter of the proximal and distal landing zone as measured on CT
94
images. A device with a diameter equal to or smaller than the aortic diameter but larger than the diameter of the
95
true lumen was selected. The true lumen diameter was calculated as the mean value of the longer and the shorter
96
diameter of the true lumen. All changes in CT imaging appearance during follow-up were recorded. Hematoma
97
regression was defined as the decreased maximum hematoma thickness ≥ 3mm. Hematoma progression was
98
defined as the increased maximum hematoma thickness ≥ 3mm. Complete resorption was defined as remaining
99
hematoma thickness ≤ 3mm.
100 6
101
Study Endpoint
102
The primary end point was death from all causes and the secondary end points were all adverse events related to
103
the aortic dissection and TEVAR, including aortic rupture, cardiac tamponade, hematoma progression need
104
reintervention, evolution to classic type A aortic dissection, new development of PAU, IMH, or classic aortic
105
dissection, PAU enlargement, and endoleak. Early aorta-related adverse event was defined as an aortic event
106
related to the aortic dissection and TEVAR within 3 months after TEVAR. Late aorta-related adverse event was
107
defined as an aortic event beyond 3 months after TEVAR.
108 109
Follow-up
110
In the study, 100% follow-up rates were achieved by the means of either a clinic follow-up or telephone contact.
111
For all patients, follow-up CT images were obtained within 3 months after TEVAR and annually thereafter. The
112
mean follow-up duration was 12.8 ± 6.9 months (range, 6-22 months).
113 114
RESULTS
115
Clinical Outcomes
116
The surgical techniques and clinical outcomes were summarized in Table 1. All patients survived surgery and
117
stent graft placement was successful in all patients. No relevant dissection, aortic rupture, neurological defect,
118
malperfusion of aortic branches, access site complication, spinal cord ischemia or endoleak was noted after
119
TEVAR. After discharge, there were three aorta-related adverse events (case 2, 5, 6). One patient (case 2) was
120
noted to have a new development of PAU at the distal aortic arch accidentally on the follow-up CT imaging, and 7
121
treated conservatively in the outpatient clinic. One patient (case 5) presented with ascending aorta hematoma
122
progression at 6-week CT follow-up after TEVAR and needed candy-plug deployment of the false lumen of the
123
descending aorta for occlusion of retrograde flow through the distal re-entry tear at the level of celiac trunk
124
(Figure 1). One patient (case 6) had developed symptomatic TAAD with a new intimal tear in the ascending aorta
125
4 months after TEVAR, although complete resorption of the false lumen after initial TEVAR was achieved (Figure
126
2). He finally underwent open aortic repair and was still alive.
127 128
Aortic Remodeling
129
The characteristics of aortic dissection and results of aortic remodeling were summarized in Table 2. After
130
TEVAR and re-TEVAR, the shrinkage of enlarged thoracic aorta and complete resorptions of the false lumen of
131
the entire thoracic aorta were observed in 5 patients, and hematoma regression was observed in 1 patient (case 2).
132
The preoperative and postoperative mean maximum aortic diameter of the ascending aorta was 46 ± 5 mm (range,
133
39-52 mm) and 43 ± 5 mm (range 35-48 mm), respectively. The stent graft was oversized to the aortic diameter at
134
the proximal and the distal landing zones by -12% ± 7% (-26% to -5%) and -3% ± 6% (-9% to 0%), respectively.
135
The stent graft was oversized to the true lumen at the proximal and the distal landing zones by 25% ± 22% (8% to
136
68%) and 14% ± 10% (3% to 30%), respectively.
137 138
DISCUSSION
139
Of all TAADs, TAIMH accounted for 22% to 28% in the East Asian studies (9, 16), and r-TAAD accounted for
140
9% to 25% of TAAD (2, 3). In our study, TAIMH and r-TAAD respectively accounted for 16% and 16% in 8
141
surgically treated TAAD patients. TAIMH has a variable course, and aortic diameter ≥ 50mm, hematoma
142
thickness ≥ 11mm, and presence of PAU are supposed to predict worse outcome (9, 10, 17, 18), that open aortic
143
repair is recommended. However, 20% TAIMH patients had PAU in the distal aortic arch or the descending aorta
144
that cannot be treated with ascending aorta and hemiarch replacement alone (19, 20). Besides, PAU enlargement
145
is common, and it is a risk factor of late aortic event if untreated (20). Grimm et al (14) successfully used stent
146
grafts to treat 8 IMH patients with plaque rupture in the distal arch to the descending aorta. Complete remodeling
147
of the entire thoracic aorta was observed in 6 patients, and classic type B aortic dissection distal to the stent graft
148
was observed in the remaining 2 patients. In our study, favorable aortic remodeling could be achieved in our 2
149
TAIMH patients without visible graft-induced intimal injury.
150
TEVAR for r-TAAD was accepted as an alternative management strategy in highly selected patients (11, 12,
151
21). The previous studies showed favorable short-term results and good remodeling of the affected aorta after
152
TEVAR, which were summarized in Table 3. However, the excellent results could not be obtained in a larger
153
series of 31 patients (22). Higashigawa et al (22) reported early aorta-related adverse events were observed in 8
154
patients (26%), including in-hospital mortality in 1 patient, the need for open aortic repair for unresolved endoleak
155
in 2 patients, and requiring additional intervention in 3 patients. At a mean follow-up of 99 months, late
156
aorta-related adverse events were observed in 7 patients (23%), including new TAAD in 3 patients, and persistent
157
endoleak in 2 patients. In our study, additional endovascular intervention for re-entry closure was required in 1
158
patient, and new TAAD developed in 1 patient, but no endoleaks were noted.
159 160
Accurate sizing of the stent graft is important to prevent endoleak and graft-induced intimal injury. In general, stent grafts are usually oversized by 5% to 10% relative to the aortic diameter of predicted landing zone and those 9
161
always depend on the aortic morphology of individual patients and surgeon experience. In our study, the stent
162
graft was oversized to the true lumen at the proximal landing zones by 25% ± 22%, less than those (34% ± 29%)
163
in the series of Higashigawa et al (22). Because the true lumen had different degree of compression by the
164
expanded false lumen, the true lumen might not be suitable as reference. So we preferred to select stent graft with
165
a diameter equal to or smaller than the maximum aortic diameter for the purpose of sealing off the entry tear.
166
Following the above principle, the short-term outcome seemed to be acceptable, and there was no graft-induced
167
intimal injury or endoleak in our study.
168
Evaluating patient suitability, using an advanced imaging system to detect the location of entry tear, correct
169
measurement of the aortic diameter, and planning the endovascular intervention are crucial for the success of
170
TEVAR. First, thin-section CT image with multiplanar reconstructive techniques rather than axial images alone
171
should be performed preoperatively for assessment of the extent of the dissection, the determination of the
172
primary entry site, and accurate measurement of the aortic diameter. Second, for adequate proximal and distal
173
landing zones to avoid endoleak, a distance between the landing site and the entry tear of at least 15 mm is
174
recommended. Insufficient landing zones may necessitate partial coverage of the left subclavian artery with or
175
without endo-wedge technique, additional intervention (chimney/periscopic technique, debranching procedure), or
176
use fenestrated stent graft. Coverage of the left subclavian artery was only performed in patients with
177
life-threatening situation and lack of the risks of vertebrobasilar ischemia and spinal cord ischemia. Third, we
178
suggest choosing sufficient conformable stent graft and selecting the size equal to or smaller than the maximum
179
aortic diameter of the landing zone.
180
To date, there is no optimal treatment strategy for r-TAAD. Although TEVAR for highly selective patients 10
181
with r-TAAD showed favorable outcome in some studies (11, 12, 21, 22), open surgical repair is still the gold
182
standard treatment for TAAD. However, for the goal of the entry closure, extended hybrid aortic repair with total
183
arch replacement and frozen elephant trunk technique had to be performed. In our study, among 7 r-TAAD
184
patients who underwent open aortic repair, ascending aorta replacement with or without hemiarch replacement
185
was performed in 2 patients, combined ascending aorta replacement and one-stage or two-stage TEVAR was
186
performed in 3 patients, and hybrid aortic repair with total arch replacement and frozen elephant trunk technique
187
was performed in 2 patients; of those, 2 patients who underwent hybrid aortic repair died of postoperative
188
refractory heart failure and mesenteric ischemia, respectively. Of these 7 patients, follow-up CT revealed
189
complete remodeling of the entire thoracic aorta in patients only when endovascular repair was performed.
190
There are several limitations to our study. First, the limited number of patients and the short duration of
191
follow-up is the most limitation of this study. Second, some patients with thinner IMH (≤ 7mm) of the ascending
192
aorta had also included, that may not be recognized as TAIMH, and was excluded in some studies.
193 194
CONCLUSION
195
Tear-oriented endovascular aortic repair is a potential therapeutic opinion in suitable cases of TAIMH and
196
rt-TAAD with the entry tear in the descending aorta or the abdominal aorta. In highly selected patient, TEVAR has
197
shown favorable short-term outcome and aortic remodeling. However, the late aorta-related adverse event is not
198
negligible, and close follow-up is mandatory. Besides, more research is warranted to provide long-term benefit.
199 200
Funding statement 11
201
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit
202
sectors.
203 204
Conflict of interest statement
205
Conflict of interest: none declared.
206 207
Figure legends
208
Figure 1. A 57-year-old male with retrograde type A aortic dissection. Preoperative CT showed thrombosed FL of
209
the ascending aorta and patent FL of the descending aorta (A). The entry tear (arrow) could be identified in the
210
descending aorta (B). CT image was obtained 6 weeks after TEVAR. The ascending aorta hematoma was still
211
seen (C) and the FL of the descending aorta was partially thrombosed (D). Retrograde flow through the distal
212
re-entry tear was seen on predeployment angiography (E) and was occluded after candy-plug deployment (F).
213
Follow-up CT showed complete resorption of the FL of the entire thoracic aorta (G and H). CT, computed
214
tomography; FL, false lumen; TEVAR, thoracic endovascular aortic repair.
215
Figure 2. A 80-year-old male with retrograde type A aortic dissection. Preoperative CT showed the FL of the
216
ascending aorta and the distal descending aorta was partially thrombosed (A) and an entry tear (arrow) could be
217
identified in the descending aorta (B). Three days later after TEVAR, follow-up CT showed complete resorption
218
of the FL of the entire thoracic aorta (C and D). Four months later, a new intimal tear in the mid ascending aorta
219
was noted on the follow-up CT imaging (E and F). CT, computed tomography; FL, false lumen; TEVAR, thoracic
220
endovascular aortic repair. 12
Reference:
1. 2.
Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation. 2005;112(24):3802-13. Kaji S, Akasaka T, Katayama M, et al. Prognosis of retrograde dissection from the descending to
the ascending aorta. Circulation. 2003;108 Suppl 1:Ii300-6. 3. Kim JB, Choo SJ, Kim WK, et al. Outcomes of acute retrograde type A aortic dissection with an entry tear in descending aorta. Circulation. 2014;130(11 Suppl 1):S39-44. 4. 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. Journal of the American College of Cardiology. 2015;66(4):350-8. 5. Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD). European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2009;37(2):149-59. 6. Cabasa A, Pochettino A. Surgical management and outcomes of type A dissection-the Mayo Clinic experience. Annals of cardiothoracic surgery. 2016;5(4):296-309. 7. Rylski B, Beyersdorf F, Kari FA, et al. Acute type A aortic dissection extending beyond ascending aorta: Limited or extensive distal repair. The Journal of thoracic and cardiovascular surgery. 2014;148(3):949-54; discussion 54. 8. Oderich GS, Karkkainen JM, Reed NR, et al. Penetrating Aortic Ulcer and Intramural Hematoma. Cardiovascular and interventional radiology. 2019;42(3):321-34. 9. 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):S292-8. 10. Kaji S, Nishigami K, Akasaka T, et al. Prediction of progression or regression of type A aortic intramural hematoma by computed tomography. Circulation. 1999;100(19 Suppl):Ii281-6. 11. Kato N, Shimono T, Hirano T, et al. Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta. Journal of vascular surgery. 2001;34(6):1023-8. 12. Shu C, Wang T, Li QM, et al. Thoracic endovascular aortic repair for retrograde type A aortic dissection with an entry tear in the descending aorta. Journal of vascular and interventional radiology : JVIR. 2012;23(4):453-60, 60.e1. 13. Araujo PV, Joviliano EE, Ribeiro MS, et al. Endovascular treatment for acute aortic syndrome. Ann Vasc Surg. 2012;26(4):516-20. 14. Grimm M, Loewe C, Gottardi R, et al. Novel insights into the mechanisms and treatment of intramural hematoma affecting the entire thoracic aorta. The Annals of thoracic surgery. 2008;86(2):453-6. 15. Lavingia KS, Ahanchi SS, Redlinger RE, et al. Aortic remodeling after thoracic endovascular aortic repair for intramural hematoma. Journal of vascular surgery. 2014;60(4):929-35; discussion 35-6. 16. Song JK, Yim JH, Ahn JM, et al. Outcomes of patients with acute type a aortic intramural hematoma. Circulation. 2009;120(21):2046-52. 13
17. 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:Ii324-8. 18. Ganaha F, Miller DC, Sugimoto K, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002;106(3):342-8. 19. Shimokawa T, Ozawa N, Takanashi S, et al. Intermediate-term results of surgical treatment of acute intramural hematoma involving the ascending aorta. The Annals of thoracic surgery. 2008;85(3):982-6. 20. Chen YY, Yen HT, Lo CM, et al. Natural courses and long-term results of type A acute aortic intramural haematoma and retrograde thrombosed type A acute aortic dissection: a single-centre experience. Interactive cardiovascular and thoracic surgery. 2019. 21. Urbanski PP, Sodah A, Matveeva A, et al. Importance of accurately locating the entry site for endovascular treatment of retrograde Type A acute aortic dissection. Interactive cardiovascular and thoracic surgery. 2018;26(5):731-7. 22. Higashigawa T, Kato N, Nakajima K, et al. Thoracic endovascular aortic repair for retrograde type A aortic dissection. Journal of vascular surgery. 2019;69(6):1685-93.
14
Table 1. Clinical Summary of Patients Treated with Endovascular Aortic Repair Case
Age, years
No.
/Sex
1
91/M
TAIMH
PAU at DesAo
27
Zone 2-3
No
6
2
69/F
rt-TAAD
AA
200
Zone 3 + coils/plug embolization
New PAU develop at distal aortic
5
of false lumen (supraceliac level)
arch
AD type
Entry site
Distance between LSC
TEVAR
Aortic events
and entry site, mm
Follow-up (months)
3
63/M
rt-TAAD
DesAo
16
Zone 2-3
No
17
4
83/M
TAIMH
PAU at DesAo
6
Zone 2 + LSC chimney
No
22
5
57/M
rt-TAAD
DesAo
25
Zone 2-3
AsAo hematoma progression need
17
re-TEVAR 6
80/M
rt-TAAD
DesAo
30
Zone 3
New classic type A AD develop
10
AA, abdominal aorta; AD, aortic dissection; AsAo, ascending aorta; DesAo, descending aorta; LSC, left subclavian artery; PAU, penetrating aortic ulcer; rt-TAAD, retrograde thrombosed type A aortic dissection; ; TAMIH, type A intramural hematoma; TEVAR, thoracic endovascular aortic repair.
Table 2. Characteristics of Aortic Dissection and Results of Aortic Remodeling after Initial Endovascular Aortic Repair Case
AsAo diameter, mm
Aortic diameter/true
Device diameter at
Aortic diameter/true
No.
/hematoma thickness, mm
lumen at proximal
proximal landing zone,
lumen at distal landing landing zone, mm
landing zone, mm
mm
zone, mm
Device diameter at distal
Thoracic aortic remodeling
1
50/4
42/37
40
35/30
32
CR
2
46/10
38/25
28
28/22
26
Regression
3
43/4
42/22
37
35/32
34
CR
4
46/6
40/33
37
31/26
31
CR
5
39/17
31/22
28
28/20
26
Progression
6
52/19
35/25
31
33/30
31
CR
AsAo, ascending aorta; CR, complete resorption.
Table 3. Summary of Previous Studies Aortic remodeling (complete TFL) Journal
Kato et al, 2001
N
10
TEVAR
Zone 3 or Zone 4 (n = 10)
(11) Shu et al, 2012
17
5
2018 (20) Our study, 2019
Aortic events
Saccular aneurysm develop below stent graft (n = 1)
follow-up
AsAo
DesAo
100%
100%
20 months
100%
41%
26 months
additional stent graft for re-entry closure (n = 1)
(12) Urbanski et al,
Mean
Zone 2 + LSC coverage (n = 4) New entry tear develop in the distal edge of the stent Zone 3 or Zone 4 (n = 13)
graft (n = 1)
Zone 2 + C-SC bypass (n = 1)
None
100%
100%
28 months
Zone 2 + LSC chimney (n = 1)
New PAU develop at distal aortic arch (n = 1)
100%
100%
13 months
Zone 3 ± embolization of false
New classic type A aortic dissection develop (n =1)
Zone 3 (n = 4) 6
lumen (n = 5) AsAo, ascending aorta; C-SC, carotid-subclavian; DesAo, Descending aorta; LSC, left subclavian artery; PAU, penetrating aortic ulcer; TEVAR, thoracic endovascular aortic repair; TFL, thrombosed false lumen.