Spontaneous false lumen thrombosis (4%) 2 4/6/2017 Intramural - - PowerPoint PPT Presentation

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William J. Quinones-Baldrich MD Professor of Surgery Director UCLA Aortic Center UCLA Medical Center Los Angeles, California

Intramural Hematoma (IMH) Should we treat this aggressively?

Disclosures

• Speaker / consultant

W.L. Gore Endologix Medtronic

Formation of thrombus in the aortic wall in the absence of a visible intimal tear or blood flow between the layers

• Can occur anywhere in the aorta (Type A or B)
• Sudden onset of chest, upper back and or abd pain
• Mimics aortic dissection
• Hypertension almost universal; refractory 30%
• 5-10 % spinal cord ischemia / infarction
• May be an incidental finding

Intramural Hematoma (IMH)

• Initial conservative management

Control BP (Same as acute dissection) Pain control

• Except if : Maximum aortic diameter ≥ 4 cm

Pleural effusion at presentation or f/u Intractable pain Refractory HTN

• Serial CTA - Days 1, 4 10

Intramural Hematoma (IMH)

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Intramural Hematoma (IMH)

Ulcer like projection (ULP) vs Penetrating aortic ulcer (PAU)

ULP vs PAU(atherosclerosis)

Intramural blood pool Areas of focal contrast enhancement within the intramural hematoma without lumen communication IMH Partially healed type B Aortic Dissection?

Spontaneous false lumen thrombosis (4%)

Initial presentation 6 weeks later

Intramural Hematoma (IMH) vs TBAD Follow up Conservative Management

2014

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Intramural Hematoma (IMH) vs TBAD Follow up Conservative Management

2015

Intramural Hematoma (IMH) vs TBAD Follow up Conservative Management

2016

Intramural Hematoma (IMH) vs TBAD Follow up Conservative Management

Feb 2017

J Vasc Surg 2013;58:1498-504

Most IMHB patients can be treated medically, and aortic enlargement is less common during follow- up, which may suggest that IMHB may have a slightly more benign course compared with classic ABAD in the acute setting. IRAD registry: IMH 107 patients vs ATBD 790 patients

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• Increase in IMH thickness
• Extension of IMH
• New Ulcer Like Projection (ULP)
• New aortic wall “pool”
• Intractable pain
• Refractory HTN

Intramural Hematoma (IMH) Indications for TEVAR on follow up

J Vasc Surg 2016;64:1569-79

• Do not exceed 10% oversizing
• Cover all affected aorta; if not possible be aware

new tear with dissection / extension can occur

• Proximal landing zone on “healthy” normal

appearing aorta

• Avoid ballooning
• Retrograde dissection is a risk – avoid bare metal

proximal stent configuration

Intramural Hematoma (IMH) TEVAR considerations

• May be a continuum of medial aortic pathology
• Conservative management is first line of therapy
• TEVAR for specific acute or subacute indications
• Close follow up indicated in all cases
• TEVAR is intervention of choice with specific

considerations

• Need for open repair very rare

Intramural Hematoma (IMH) Conclusions

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UCLA Aortic Center

aorticcenter.ucla.edu

310-AORTAFIX (310-267-8234)

Thank you