Ascending intramural hematoma (IMH) -- Does it really occlude arch branch vessels?
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0060
Submission Type:
Abstract Submission
Authors:
Sanya Abbasey (1), Asanish Kalyanasundaram (2), John Elefteriades (2), Mohammad Zafar (2)
Institutions:
(1) Yale University, New Haven, CT, (2) Yale New Haven Hospital, New Haven, CT
Submitting Author:
Sanya Abbasey
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Yale University
Yale University
Co-Author(s):
Asanish Kalyanasundaram
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Yale New Haven Hospital
Yale New Haven Hospital
*John Elefteriades
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Yale New Haven Hospital
Yale New Haven Hospital
Mohammad Zafar
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Yale New Haven Hospital
Yale New Haven Hospital
Presenting Author:
Sanya Abbasey
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Abstract:
Background:
The 2022 AATS Aortic Guidelines indicate that for ascending aortic intramural hematoma (IMH) branch vessel involvement is an appropriate indication for surgical intervention. Not recalling branch vessel involvement by this entity, we investigated its true prevalence.
Methods:
We reviewed scans of 3055 patients in our aortic database to identify patients with ascending IMH. IMH was defined as concentric intramural hemorrhage without dissection flap or ulceration. We excluded patients with penetrating aortic ulcers (PAU) in addition to the ascending IMH. Of 628 patients with acute aortic syndromes, 22 patients with ascending IMH were identified. 19 patients with available scans meeting these criteria were identified. Their CT/MRI scans were reviewed in detail by a multi-member team with experience in interpreting such images. On contrast and non-contrast CT scans, IMH was identified as a hyper dense circular zone forming a rim around the main aortic lumen, and without a dissection flap appearing across the aortic lumen. The scans were reviewed to determine the frequency and degree of arch branch vessel occlusion.
Results:
Among the 19 patients, there were 10 females and 9 males aged 50-84 (mean age 70.3, median 71.5). The maximum ascending aortic diameter at presentation ranged from 42.7 to 59.6mm, with a mean of 50.6mm. All patients were treated with anti-impulse therapy (beta blocker and after load reduction) in an ICU setting. The IMH was limited to the ascending aorta in 5 cases and extended to the descending aorta in 14. 13 patients required surgery during the initial hospitalization, and the remainder were treated solely medically. Of those who were operated, 12 (92.3%) survived hospitalization and 1 (7.7%) died within 1 month post-operatively. Patient follow-up was 100% complete (0.1 to 22.3 years, mean 7.0). 11 patients died during follow-up. It was confirmed that 0 patients died directly of rupture. Of the IMHs in the discharged patients, 3 resolved spontaneously within 1.5-4 months and 0 progressed to typical aortic dissection. 0 of the total 19 patients manifested involvement of the great vessels, including innominate, left carotid, left subclavian. For all observed cases, blood flow to the great vessels was unimpaired.
Conclusion:
Branch vessel involvement from ascending IMH seems a rare phenomenon. If experience from other institutions is found to be similar, the surgical stipulation in the Guidelines may not be necessary.
The 2022 AATS Aortic Guidelines indicate that for ascending aortic intramural hematoma (IMH) branch vessel involvement is an appropriate indication for surgical intervention. Not recalling branch vessel involvement by this entity, we investigated its true prevalence.
Methods:
We reviewed scans of 3055 patients in our aortic database to identify patients with ascending IMH. IMH was defined as concentric intramural hemorrhage without dissection flap or ulceration. We excluded patients with penetrating aortic ulcers (PAU) in addition to the ascending IMH. Of 628 patients with acute aortic syndromes, 22 patients with ascending IMH were identified. 19 patients with available scans meeting these criteria were identified. Their CT/MRI scans were reviewed in detail by a multi-member team with experience in interpreting such images. On contrast and non-contrast CT scans, IMH was identified as a hyper dense circular zone forming a rim around the main aortic lumen, and without a dissection flap appearing across the aortic lumen. The scans were reviewed to determine the frequency and degree of arch branch vessel occlusion.
Results:
Among the 19 patients, there were 10 females and 9 males aged 50-84 (mean age 70.3, median 71.5). The maximum ascending aortic diameter at presentation ranged from 42.7 to 59.6mm, with a mean of 50.6mm. All patients were treated with anti-impulse therapy (beta blocker and after load reduction) in an ICU setting. The IMH was limited to the ascending aorta in 5 cases and extended to the descending aorta in 14. 13 patients required surgery during the initial hospitalization, and the remainder were treated solely medically. Of those who were operated, 12 (92.3%) survived hospitalization and 1 (7.7%) died within 1 month post-operatively. Patient follow-up was 100% complete (0.1 to 22.3 years, mean 7.0). 11 patients died during follow-up. It was confirmed that 0 patients died directly of rupture. Of the IMHs in the discharged patients, 3 resolved spontaneously within 1.5-4 months and 0 progressed to typical aortic dissection. 0 of the total 19 patients manifested involvement of the great vessels, including innominate, left carotid, left subclavian. For all observed cases, blood flow to the great vessels was unimpaired.
Conclusion:
Branch vessel involvement from ascending IMH seems a rare phenomenon. If experience from other institutions is found to be similar, the surgical stipulation in the Guidelines may not be necessary.
Aortic Symposium:
Ascending Aorta
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