IMH/Penetrating Aortic Ulcers/ Saccular Aneurysms: How to manage - - PowerPoint PPT Presentation

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 Aneurysm
• 3. Focal Dissection
• 4. 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

9 Bosson 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 Therapy
• 2. TEVAR
• 3. Open Repair

Treatment Options?

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Follow Up CTA in 2 weeks

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• 1. Anti-impulse Therapy
• 2. Zone 3 TEVAR
• 3. Zone 2 TEVAR
• 4. Zone 1 TEVAR
• 5. 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
• f the stent graft

TEVAR for IMH

19 Evangelista 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 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

• 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

24 Evangelista 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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