Long-term Follow-up of Aortic Intramural Hematomas and Penetrating Ulcers Alan S. Chou, BA, Bulat A. Ziganshin, MD, Paris Charilaou, MD, Maryann Tranquilli,

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Presentation transcript:

Long-term Follow-up of Aortic Intramural Hematomas and Penetrating Ulcers Alan S. Chou, BA, Bulat A. Ziganshin, MD, Paris Charilaou, MD, Maryann Tranquilli, RN, John A. Rizzo, PhD, John A. Elefteriades, MD Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine New Haven, Connecticut, USA Presented at the 95 th Annual Meeting of the American Association of Thoracic Surgery April 28 th,

Disclosures Alan S. Chou, BA: – Nothing to disclose. Bulat A. Ziganshin, MD: – Nothing to disclose. Paris Charilaou, MD: – Nothing to disclose. Maryann Tranquilli, RN: – Nothing to disclose. John A. Rizzo, PhD: – Nothing to disclose. John A. Elefteriades, MD: – DSMB for Jarvik Heart, Solus Valve; Research Grant Vascutek; Medical Director for CoolSpine. 2

Acute Aortic Syndromes 3 Elefteriades JA. Thoracic aortic aneurysm: reading the enemy’s playbook. Curr Probl Cardiol. 2008;33:203–77.

Current literature/evidence 4

5

US and European Guidelines 6

Aim of the study To evaluate the long-term natural history and progression of intramural hematomas and penetrating aortic ulcers including clinical and radiological follow-up and survival analysis. 7

Progression of Lesions 8

9 Resolution

Progression of Lesions 10 Resolution No Change (Stable)

Progression of Lesions 11 Resolution No Change (Stable) Worsening

Patient profile consecutive patients ( ) 108 consecutive patients ( )

Patient profile consecutive patients ( ) 108 consecutive patients ( ) 55 IMH patients (51%) 55 IMH patients (51%) 53 PAU patients (49%) 53 PAU patients (49%)

Patient profile consecutive patients ( ) 108 consecutive patients ( ) 55 IMH patients (51%) 55 IMH patients (51%) 56% Female 53 PAU patients (49%) 53 PAU patients (49%) 57% Female

Patient profile consecutive patients ( ) 108 consecutive patients ( ) 55 IMH patients (51%) 55 IMH patients (51%) 56% Female 53 PAU patients (49%) 53 PAU patients (49%) 57% Female All patients were symptomatic at presentation All patients were symptomatic at presentation

Age of IMH and PAU Patients 16 Mean age IMH — 70.3±10 yrs Mean age PAU — 71.4±10 yrs

Location Distribution 17

Intramural Hematoma 18

Hospital Course of IMH Patients with IMH 55 Patients with IMH

Hospital Course of IMH Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10)

Hospital Course of IMH Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin 1999;17: High incidence of rupture at presentation compared with 8% and 4% for classic Type A and B dissection previously observed (p<0.05)

Hospital Course of IMH Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) 56% Initial Medical Tx (n = 25) 56% Initial Medical Tx (n = 25) 44% Initial Surgical Tx (n = 20) 44% Initial Surgical Tx (n = 20) 30% Initial Medical Tx (n = 3) 30% Initial Medical Tx (n = 3) 70% Initial Surgical Tx (n = 7) 70% Initial Surgical Tx (n = 7)

Hospital Course of IMH Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) 56% Initial Medical Tx (n = 25) 56% Initial Medical Tx (n = 25) 44% Initial Surgical Tx (n = 20) 44% Initial Surgical Tx (n = 20) 30% Initial Medical Tx (n = 3) 30% Initial Medical Tx (n = 3) 70% Initial Surgical Tx (n = 7) 70% Initial Surgical Tx (n = 7) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 20) 100% Survived to Discharge (n = 20)

Hospital Course of IMH Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) 56% Initial Medical Tx (n = 25) 56% Initial Medical Tx (n = 25) 44% Initial Surgical Tx (n = 20) 44% Initial Surgical Tx (n = 20) 30% Initial Medical Tx (n = 3) 30% Initial Medical Tx (n = 3) 70% Initial Surgical Tx (n = 7) 70% Initial Surgical Tx (n = 7) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 20) 100% Survived to Discharge (n = 20) 0% Survived to Discharge (n = 0) 0% Survived to Discharge (n = 0) 43% Survived to Discharge (n = 3) 43% Survived to Discharge (n = 3)

IMH does not occlude branch vessels No branch occlusion among any IMH patients Contrast with classic flap dissection 25

Radiologic Follow-up of Medically managed IMH 26 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months)

Radiologic Follow-up of Medically managed IMH 27 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months) 29% Resolution (n = 4) 29% Resolution (n = 4)

Radiologic Follow-up of Medically managed IMH 28 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months) 29% Resolution (n = 4) 29% Resolution (n = 4) 14% Stable (n = 2) 14% Stable (n = 2)

Radiologic Follow-up of Medically managed IMH 29 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months) 29% Resolution (n = 4) 29% Resolution (n = 4) 57% Worsening (n = 8) Mean time – 1.3 mo. 57% Worsening (n = 8) Mean time – 1.3 mo. 14% Stable (n = 2) 14% Stable (n = 2)

Radiologic Follow-up of Medically managed IMH 30 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months) 29% Resolution (n = 4) 29% Resolution (n = 4) 57% Worsening (n = 8) Mean time – 1.3 mo. 57% Worsening (n = 8) Mean time – 1.3 mo. 14% Stable (n = 2) 14% Stable (n = 2) 75% Underwent late surgery (n = 6) 75% Underwent late surgery (n = 6)

Surgical Treatment of IMH 31 Mean Post-Surgical Follow-up — 39.6 months (range 2-140)

Penetrating Aortic Ulcer 32

Hospital Course of PAU Patients with PAU 53 Patients with PAU

Hospital Course of PAU Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17)

Hospital Course of PAU Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) High incidence of rupture at presentation compared with 8% and 4% for classic Type A and B dissection previously observed (p<0.001) Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin 1999;17:

Hospital Course of PAU Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) 69% Initial Medical Tx (n = 25) 69% Initial Medical Tx (n = 25) 31% Initial Surgical Tx (n = 11) 31% Initial Surgical Tx (n = 11) 29% Initial Medical Tx (n = 5) 29% Initial Medical Tx (n = 5) 71% Initial Surgical Tx (n = 12) 71% Initial Surgical Tx (n = 12)

Hospital Course of PAU Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) 69% Initial Medical Tx (n = 25) 69% Initial Medical Tx (n = 25) 31% Initial Surgical Tx (n = 11) 31% Initial Surgical Tx (n = 11) 29% Initial Medical Tx (n = 5) 29% Initial Medical Tx (n = 5) 71% Initial Surgical Tx (n = 12) 71% Initial Surgical Tx (n = 12) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 11) 100% Survived to Discharge (n = 11)

Hospital Course of PAU Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) 69% Initial Medical Tx (n = 25) 69% Initial Medical Tx (n = 25) 31% Initial Surgical Tx (n = 11) 31% Initial Surgical Tx (n = 11) 29% Initial Medical Tx (n = 5) 29% Initial Medical Tx (n = 5) 71% Initial Surgical Tx (n = 12) 71% Initial Surgical Tx (n = 12) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 11) 100% Survived to Discharge (n = 11) 0% Survived to Discharge (n = 0) 0% Survived to Discharge (n = 0) 87% Survived to Discharge (n = 10) 87% Survived to Discharge (n = 10)

Radiologic Follow-up of Medically managed PAU 39 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months)

Radiologic Follow-up of Medically managed PAU 40 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months) 15% Resolution (n = 3) 15% Resolution (n = 3)

Radiologic Follow-up of Medically managed PAU 41 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months) 15% Resolution (n = 3) 15% Resolution (n = 3) 55% Stable (n = 11) 55% Stable (n = 11)

Radiologic Follow-up of Medically managed PAU 42 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months) 15% Resolution (n = 3) 15% Resolution (n = 3) 30% Worsening (n = 6) Mean time – 18 mo. 30% Worsening (n = 6) Mean time – 18 mo. 55% Stable (n = 11) 55% Stable (n = 11)

Radiologic Follow-up of Medically managed PAU 43 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months) 15% Resolution (n = 3) 15% Resolution (n = 3) 30% Worsening (n = 6) Mean time – 18 mo. 30% Worsening (n = 6) Mean time – 18 mo. 55% Stable (n = 11) 55% Stable (n = 11) 100% Underwent late surgery (n = 6) 100% Underwent late surgery (n = 6)

Surgical Treatment of PAU 44 Mean Post-Surgical Follow-up — 42.9 months (range 1-150)

Long Term Survival of IMH and PAU 45

Comparison of IMH vs PAU Survival 46 p = 0.26

Comparison of IMH vs PAU Survival 47 p = 0.26

Medical vs Surgical Treatment of IMH 48

Medical vs Surgical Treatment of IMH 49 p = 0.10 (log-rank)

Medical vs Surgical Treatment of IMH 50 p = (Gehan-Breslow-Wilcoxon test)

Medical vs Surgical Treatment of PAU 51

Medical vs Surgical Treatment of PAU 52 p = 0.037

Important points – IMH and PAU 1.Disease of the elderly population. 2.Female gender predominates. 3.High rupture rates upon initial presentation. 4.No branch occlusion. 5.True healing does occur, but worsening is more common. 6.Surgical approach is safe and yields improved survival. 7.Results of this study support an expectant, but aggressive approach towards IMH and PAU. 53

56

57

Worsening — Refers to deterioration in aortic condition, including significant increases in the thickness or depth of the lesion, progression of PAU to IMH (or vice versa), progression to classic dissection, or rupture. Intramural Hematoma 57% (n=8) of patients worsened: – 38% conversion to flap dissection, – 38% appearance of a concurrent penetrating ulcer, – 25% rapid expansion of the IMH The mean time to detection of worsening was 1.3 months (range ) Penetrating Aortic Ulcers 30% (n=6) of patients worsened: – 33% conversion to flap dissection, – 66% expansion of the ulcer and appearance of associated intramural hematoma. The mean time to worsening was 18.0 months (range 1-92) 58

Causes of Death 59

Total Cohort Survival (IMH+PAU) 60 1-year — 77% 3-year— 70% 5-year — 58% 10-year — 33%

Rupture/Impending Rupture Rupture Defined as the presence of extra-aortic blood confirmed by: – Radiology, – Surgical examination, – Post-mortem examination. Impending Rupture Confirmed by an experienced aortic surgeon or radiologist, given the presence of the following: – Bloody effusion, – Rapid radiologic worsening, – Increase in effusion amount, – Persistent pain, – Intraoperative findings. 61

General Management Strategy Operate on all rupture state patients and all ascending lesions when clinically possible. For descending IMH and PAU, we provided standard initial non-surgical anti-impulse therapy, yet maintained a low threshold for surgical intervention in case of severe, recurrent symptoms or radiographic worsening upon follow-up. Our policy originated in the pre-endovascular era, and the majority of our operatively treated patients underwent open repair rather than endovascular treatment. 62

Surgical Treatment by Location (IMH) Initial ManagementLate Management 63

Thromboexclusion procedure 64

65

Hospital Course of IMH Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) 56% Initial Medical Tx (n = 25) 56% Initial Medical Tx (n = 25) 44% Initial Surgical Tx (n = 20) 44% Initial Surgical Tx (n = 20) 30% Initial Medical Tx (n = 3) 30% Initial Medical Tx (n = 3) 70% Initial Surgical Tx (n = 7) 70% Initial Surgical Tx (n = 7) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 20) 100% Survived to Discharge (n = 20) 0% Survived to Discharge (n = 0) 0% Survived to Discharge (n = 0) 43% Survived to Discharge (n = 3) 43% Survived to Discharge (n = 3)

Hospital Course of PAU Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) 69% Initial Medical Tx (n = 25) 69% Initial Medical Tx (n = 25) 31% Initial Surgical Tx (n = 11) 31% Initial Surgical Tx (n = 11) 29% Initial Medical Tx (n = 5) 29% Initial Medical Tx (n = 5) 71% Initial Surgical Tx (n = 12) 71% Initial Surgical Tx (n = 12) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 11) 100% Survived to Discharge (n = 11) 0% Survived to Discharge (n = 0) 0% Survived to Discharge (n = 0) 87% Survived to Discharge (n = 10) 87% Survived to Discharge (n = 10)

Comorbidities of IMH and PAU patients 68