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

•  Cook Medical: Consultant, Proctor for TX2, Zenith, Alpha, Zenith Fenestrated

•  Gore & Associates: Consultant

DISCLOSURES

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1.  PAU with associated IMH

2.  Saccular Aneurysm3.  Focal Dissection4.  IMH with associated

ULP

What is the diagnosis?

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Aortic Dissection

Penetrating Aortic Ulcer

Intramural Hematoma

Saccular Aneurysm

•  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

Intramural Hematoma (IMH)

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Imaging for IMH

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•  Regression (10~40%)•  Progression to aortic rupture (20~45%)•  Progression to aortic dissection (28~47%)

•  Regional variations in reported risks•  Asia: more benign?

Natural Course of IMH

9Bosson et al. E Heart J. 2018

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•  Type A•  Persistent/Recurrent

pain despite optimal anti-impulse therapy

•  Refractory HTN•  Rapid growth•  High risk features

Indications for Repair

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Predictors of Adverse Aortic Event in Medically Managed Type B IMH

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•  Initial aortic diameter > 40mm•  Thickness of IMH > 10mm•  Development of ULP >

10~15mm•  Age > 70 y/o

•  Pleural effusion

Case

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•  65 M with sudden chest pain radiating to back

•  PMH/PSH: HTN •  Fam Hx: no

aortopathy

1.  Anti-impulse Therapy2.  TEVAR3.  Open Repair

Treatment Options?

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Follow Up CTA in 2 weeks

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1.  Anti-impulse Therapy2.  Zone 3 TEVAR3.  Zone 2 TEVAR4.  Zone 1 TEVAR5.  Total Arch Repair with (Frozen) Elephant

Trunk

Treatment Options?

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Zone 2 TEVAR + CCA-LSCA BPG

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Post TEVAR CTA

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•  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

TEVAR for IMH

19Evangelista et al. Eur J Cardiothorac Surg, 2015.

•  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

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Endovascular Stent-graft Management of AorticIntramural HematomasValérie Monnin-Bares, MD, Frédéric Thony, MD, Mathieu Rodiere, MD, Vincent Bach, MD, Rachid Hacini, MD,

Dominique Blin, PhD, and Gilbert Ferretti, PhD

PURPOSE: To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH).

MATERIALS AND METHODS: From 2000 to 2006, 15 patients (mean age, 67 years; range, 54–83 y) underwentendovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two fortraumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH,n ! 3; type B IMH, n ! 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH,n ! 1; type B IMH, n ! 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The meanfollow-up was 21 months (range, 6–72 months).

RESULTS: The primary success rate was 93%, with complete exclusion of the lesion (n ! 14). Exclusion was partial forone patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases,with decreased aortic wall thickening (n ! 8) or complete regression (n ! 7). Complications associated withendovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%.

CONCLUSIONS: Endovascular stent-graft treatment can be performed in the management of complicated IMH, evenin some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindi-cations to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic optionespecially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.

J Vasc Interv Radiol 2009; 20:713–721

Abbreviation: IMH ! intramural hematoma

IN the past decade, in patients withacute aortic syndromes, intramural he-matoma (IMH) of the thoracic aortahas become increasingly recognized asa pathologic entity distinct from dis-section (1). However, there is no estab-lished consensus regarding optimalmanagement strategies for the disease.Clinicians have to weigh the benefitsand risks for their patients between

surgical management (with high asso-ciated morbidity and mortality rates)and medical management (with therisk of complications such as aorticrupture, classical dissection, or aneu-rysm formation). Endovascular stent-graft management is currently sug-gested by some authors as a thirdtherapeutic option that offers an inter-esting alternative to conventional opensurgery to treat some complicated IMHswith associated intimal defects (1–4).This treatment of IMH has scarcely beendescribed in the literature (1,5–8), andonly with small samples of patients. Inaddition, we are aware of none thathave reported endovascular manage-ment of IMH involving the ascendingaorta.

Two different mechanisms havebeen proposed to explain hematomaformation within the aortic wall. Oneis a spontaneous rupture of aortic vasa

vasorum (without intimal disruption)(9). The other pathophysiologic pro-cess is an atherosclerotic ulcer thatpenetrates into the internal elastic lam-ina and allows hematoma formationwithin the media of the aortic wall(10). Improvements in vascular imag-ing technology (eg, multi–detectorrow computed tomography [CT]), inaddition to surgical data, have led to agrowing recognition of intimal disrup-tion as a small entry tear responsiblefor hematoma formation within themedia of the aortic wall (11,12). Theseulcerlike lesions represent ideal tar-gets for endovascular treatment, evenin the case of involvement of the as-cending aorta. Moreover, in these pa-tients who are typically not ideal candi-dates for surgery because of theiradvanced age—the mean age of patientswith IMH is approximately 70 years(1,13,14)—and/or coexisting medical

From the Departments of Radiology (V.M.-B., F.T.,M.R., G.F.) and Thoracic and Cardiovascular Sur-gery (V.B., R.H., D.B.), Centre Hospitalier Universi-taire A. Michallon, Grenoble University 1, LaTronche, BP217, Grenoble 38043, France. ReceivedFebruary 12, 2008; final revision received January 30,2009; accepted February 4, 2009. Address correspon-dence to V.M.B.; E-mail: val_monnin@yahoo.fr

None of the authors have identified a conflict ofinterest.

© SIR, 2009

DOI: 10.1016/j.jvir.2009.02.013

Clinical Studies

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•  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

Technical considerations for TEVAR for IMH

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•  Erosion of mural atheroma, causing focal blood flow into the aortic wall without flap

•  Associated IMH

•  Older, more cardiovascular atherosclerotic comorbidities

Penetrating Aortic Ulcer

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•  Clinical or radiologic signs of rupture

•  Persistent pain despite optimal medical treatment

•  Large associated IMH > 11mm •  Total aortic diameter > 50mm •  Periaortic pleural effusion

When to intervene on PAU?

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•  Perioperative mortality 7.2% (vs 16% in open repair)

•  Access issues•  Associated IMH

TEVAR for PAU

24Evangelista et al. Eur J Cardiothorac Surg, 2015.

•  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

Summary

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