Treatment indications for and outcome of endovascular repair of type B intramural aortic hematoma Moritz S. Bischoff, MD, Katrin Meisenbacher, MD, Michael.

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Presentation transcript:

Treatment indications for and outcome of endovascular repair of type B intramural aortic hematoma Moritz S. Bischoff, MD, Katrin Meisenbacher, MD, Michael Wehrmeister, MD, Dittmar Böckler, MD, Drosos Kotelis, MD Journal of Vascular Surgery Volume 64, Issue 6, Pages 1569-1579.e2 (December 2016) DOI: 10.1016/j.jvs.2016.05.078 Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 1 Contrast-enhanced computed tomography angiography (CTA) of a 62-year-old man presenting with sudden thoracic pain who underwent thoracic endovascular aortic repair (TEVAR). CTA at admission (A) showed intramural hematoma type B (IMHB) of the descending thoracic aorta. The patient received antihypertensive treatment as well as pain management in an intensive care unit setting, and control scans during the hospital stay showed stable disease. Therefore, conservative treatment with a quadruple antihypertensive medication was continued. Planned control CTA 6 weeks after discharge (B, sagittal orientation; C, axial orientation; D, three-dimensional reconstruction) showed disease progression in terms of a new evolved ulcerlike projection (ULP) in the descending thoracic aorta; aortic diameter at this site progressed to 43 mm. Elective TEVAR was performed, with successful exclusion of the ULP (E). A, Anterior. Journal of Vascular Surgery 2016 64, 1569-1579.e2DOI: (10.1016/j.jvs.2016.05.078) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 2 Contrast-enhanced computed tomography angiography (CTA) of a 45-year-old woman presenting with lower back pain, dyspnea, and primary paraparesis who underwent thoracic endovascular aortic repair (TEVAR). CTA at admission (A) showed intramural hematoma type B (IMHB) of the descending thoracic aorta. As primary paraparesis completely resolved and there were no signs of end-organ ischemia, the patient was transferred to an intensive care unit for conservative treatment. Due to recurrent pain, a control scan was performed on the third in-hospital day, revealing numerous new intramural blood pools along the entire IMH (B, sagittal orientation; C, axial orientation). Therefore, TEVAR was performed 5 days after admission. Five-year follow-up displayed complete remodeling of the aorta (D, sagittal orientation; E, centerline measurement). Journal of Vascular Surgery 2016 64, 1569-1579.e2DOI: (10.1016/j.jvs.2016.05.078) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 3 Indications leading to thoracic endovascular aortic repair (TEVAR; multiple selections possible). Upper figure, Initial TEVAR. Lower figure, Cases crossing over to TEVAR during surveillance. IMH, Intramural hematoma; IMHT, IMH thickness; MAD, maximum aortic diameter; PAU, penetrating aortic ulcer; RR, hypertension; progr., progressive; ULP, ulcerlike projection. Journal of Vascular Surgery 2016 64, 1569-1579.e2DOI: (10.1016/j.jvs.2016.05.078) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 4 Contrast-enhanced computed tomography angiography (CTA) of an 81-year-old female nonsurgical patient. CTA at admission (A) displayed an intramural hematoma type B (IMHB) of the descending thoracic aorta. CTA after 14 days (B) showed stable disease. A follow-up scan obtained 13 months after presentation detected distinct IMH regression in axial (C) and sagittal (D) slices. Journal of Vascular Surgery 2016 64, 1569-1579.e2DOI: (10.1016/j.jvs.2016.05.078) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 1 (online only) A, Centerline postprocessing of computed tomography angiography (CTA) scan showing intramural hematoma Stanford type B (IMHB). B, The perpendicular view shows an example of crescentic thickening of the aortic wall (arrow), demonstrating the evaluation of maximum aortic diameter (MAD) and intramural hematoma thickness (IMHT). Journal of Vascular Surgery 2016 64, 1569-1579.e2DOI: (10.1016/j.jvs.2016.05.078) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 2 (online only) Examples of penetrating aortic ulcer (PAU) showing a distinct correlation to atherosclerotic disease. A, PAU in a native-phase computed tomography (CT) scan, axial orientation. B, Contrast-enhanced CT angiography (CTA) at the same level, axial orientation. C, Sagittal view of a thoracic PAU. Journal of Vascular Surgery 2016 64, 1569-1579.e2DOI: (10.1016/j.jvs.2016.05.078) Copyright © 2016 Society for Vascular Surgery Terms and Conditions