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Thoracic Endovascular Aortic Repair for Intramural Hematoma: Safe and Effective Treatment Promoting Aortic Remodeling
Kedar S Lavingia, Richard E Redlinger, Jr., Navalkishor R Udgiri, Sadaf S Ahanchi, Jean M Panneton
Eastern Virginia Medical School, Norfolk, VA

Background:
Intramural hematoma (IMH), penetrating aortic ulcer (PAU), and aortic dissection (AD) comprise a spectrum of acute aortic pathologies. While thoracic endovascular aortic repair (TEVAR) has increasingly been applied to AD, there is a paucity of data on the impact of TEVAR for IMH on aortic anatomy. Our goal was to investigate the extent of aortic remodeling after TEVAR for IMH.
Methods:
A retrospective chart review of patients from 2004 to 2012 was conducted on patients with IMH with or without PAU. Charts were reviewed in a retrospective manner to collect data detailing: demographics, indications for surgery, operative notes, and office progress notes. Radiology images were reviewed and primary data points included indices of the aortic true lumen (TL) and total aortic diameter at site of pathology (TAD). Aortic remodeling was evidenced by a TAD/TL ratio closest to 1.0. Patients with no pre-operative CT scan, or no imaging after 30 days of operation were not included for imaging analysis.
Results:
During our 8 year period, 216 endovascular thoracic aortic repairs were reviewed. 48 patients were found to have an IMH on presentation for repair. 25 of the 48 patients had an IMH with concomitant PAU. Of the total cohort, 18 were male with a mean age of 70.2 years ± 10(SD). 46 (96%) of patients had diagnoses of hypertension, 34(71%) were smokers, and 7(19%) had CAD or prior myocardial infarction. Indications for operation included intractable pain in 34 (69%), uncontrolled HTN in 6 (13%) and rupture in 8 (17%). Technically successful TEVAR was performed in all patients with 45 (94%) reporting relief of symptoms post procedure. Adjunctive procedures were performed in 19 (40%): 7 (14%) arch debranching, 6 (12%) laser fenestration, and 6 (12%) iliac conduit. Post procedurally, the 30 day mortality rate was 6% with a 4% rate of permanent paraplegia. At a mean follow up of 11.6 months, the overall survival was 69% with a reintervention rate of 12%.
For our imaging analysis, 12 patients were excluded due to lack of follow up imaging after 30 days resulting in the analysis of 36 CT scans. Imaging revealed that the pre-operative ratio of TAD/TL was 1.33 ± 0.13. The mean number of days to follow up CT was 383 days with a range of 48 to 1486 days. There was a significant decrease in the post-operative TAD/TL ratio to 1.10 ± 0.10 (vs preoperative TAD/TL ratio, P<.001). 3(8%) patients had subsequent repeat TEVAR procedure either due to proximal endoleak or graft migration. The mean change in TAD/TL ratio from pre to post-operative for the reinterventions was 0.14, while the mean change in TAD/TL ratio from pre to post-operative for the non reinterventions was 0.27(p<.001).
Conclusions:
Although more longitudinal studies are necessary, endograft therapies for IMH, when anatomically possible, promote aortic remodeling, and potentially, complete long term resolution.


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