IMH/Penetrating Aortic Ulcers/ Saccular Aneurysms: How to manage and when to intervene UCSF Vascular Surgery Symposium 2018 Sukgu M Han, MD, MS Assistant Professor of Clinical Surgery Co-director, Comprehensive Aortic Center Division of Vascular Sugery and Endovascular Therapy Keck Medical Center of USC Sukgu.han@med.usc.edu
DISCLOSURES • Cook Medical: Consultant, Proctor for TX2, Zenith, Alpha, Zenith Fenestrated • Gore & Associates: Consultant 2
What is the diagnosis? 1. PAU with associated IMH 2. Saccular Aneurysm 3. Focal Dissection 4. IMH with associated ULP 3
Aortic Dissection Intramural Penetrating Aortic Hematoma Ulcer Saccular Aneurysm 4
Intramural Hematoma (IMH) • Hematoma within the media without open communiation to the lumen via intimal flap • Pathophysiology: • Rupture of vasa vasorum, intimomedial tear (vs thrombosed false lumen) • Similar presentation as aortic dissection • Rare malperfusion • 5~30% of acute aortic syndromes • Type A/B IMH 5
Imaging for IMH 6
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Natural Course of IMH • Regression (10~40%) • Progression to aortic rupture (20~45%) • Progression to aortic dissection (28~47%) • Regional variations in reported risks • Asia: more benign? Bosson et al. E Heart J. 2018 9
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Indications for Repair • Type A • Persistent/Recurrent pain despite optimal anti-impulse therapy • Refractory HTN • Rapid growth • High risk features 11
Predictors of Adverse Aortic Event in Medically Managed Type B IMH • Initial aortic diameter > 40mm • Thickness of IMH > 10mm • Development of ULP > 10~15mm • Age > 70 y/o • Pleural effusion 12
Case • 65 M with sudden chest pain radiating to back • PMH/PSH: HTN • Fam Hx: no aortopathy 13
Treatment Options? 1. Anti-impulse Therapy 2. TEVAR 3. Open Repair 14
Follow Up CTA in 2 weeks 15
Treatment Options? 1. Anti-impulse Therapy 2. Zone 3 TEVAR 3. Zone 2 TEVAR 4. Zone 1 TEVAR 5. Total Arch Repair with (Frozen) Elephant Trunk 16
Zone 2 TEVAR + CCA-LSCA BPG 17
Post TEVAR CTA 18
TEVAR for IMH • Perioperative mortality after TEVAR in acute IMH ~ 4.6% (vs Open Repair of acute IMH ~ 16%) • Endoleak/stent-induced tear • Pseudoaneurysms at ends of the stent graft Evangelista et al. Eur J Cardiothorac Surg, 2015. 19
Endovascular Stent-graft Management of Aortic Intramural Hematomas Valérie Monnin-Bares, MD, Frédéric Thony, MD, Mathieu Rodiere, MD, Vincent Bach, MD, Rachid Hacini, MD, Dominique Blin, PhD, and Gilbert Ferretti, PhD • 15 TEVAR performed for type A, and B IMH • All cases with identifiable intimal flap • Targeted lesion= intimal flap • Shortest stent grafts used • Landing in descending even in type A IMH 20
Technical considerations for TEVAR for IMH • Conservative oversizing 10% • Coverage of entire IMH may require extensive aorta coverage and coverage of aortic branches • Proximal edge of the seal zone must be in healthy aorta (15mm length) • Often requires left SCA coverage • Risk of retrograde dissection 21
Penetrating Aortic Ulcer • Erosion of mural atheroma, causing focal blood flow into the aortic wall without flap • Associated IMH • Older, more cardiovascular atherosclerotic comorbidities 22
When to intervene on PAU? • Clinical or radiologic signs of rupture • Persistent pain despite optimal medical treatment • Large associated IMH > 11mm • Total aortic diameter > 50mm • Periaortic pleural effusion 23
TEVAR for PAU • Perioperative mortality 7.2% (vs 16% in open repair) • Access issues • Associated IMH Evangelista et al. Eur J Cardiothorac Surg, 2015. 24
Summary • IMH/PAU/Aortic Dissections can rapidly evolve • Surgical repair first line therapy in type A IMH/ PAU • Conservative management first line therapy in type B IMH/PAU… with close surveillance! • TEVAR with conservative landing zone 25
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