P174. Initial treatment for Acute Type A Intramural Hematoma: Medical Treatment vs Surgical Repair

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Objective: Acute type A aortic dissection is generally indicated for emergency surgery. However, Japanese guidelines propose medical treatment as an option for acute type A intramural hematoma (ATAIMH) characterized by thrombosed false lumen in the ascending aorta, provided certain criteria are met. The diameter of the ascending aorta is <50 mm, the diameter of the false lumen is <11 mm, and there is no cardiac tamponade or vital organ malperfusion. The choice of treatment for ATAIMH is still controversial. This study aimed to compare outcomes between emergency surgery and conservative (medical) treatment for ATAIMH and identify factors leading to surgical intervention after medical management.
Methods: From January 2013 to December 2023, 46 consecutive patients with ATAIMH who were urgently admitted to our hospital were included in the study. 25 patients in the emergency surgery group (S group) and 21 patients in the medical treatment group (M group) were compared.
Results: The mean age of the patients was 71.5±9.4 years, with 54% females, showing no significant difference between the groups.10 (40%) patients in the S group experienced hemodynamic instability due to cardiac tamponade and 15 (60%) had a false lumen diameter >11 mm in the ascending aorta, prompting surgical intervention. The false lumen diameter was significantly larger in the S group than in the M group (14.3±8.1 mm vs. 7.8±1.8 mm, P<0.001). The range of aortic replacement was only ascending aorta (AR) in 6 cases, partial arch (PAR) in 16 cases, total arch (TAR) in 2 cases, and aortic root replacement (ARR) in 1 case. Preoperative enhanced computed tomography (CT) showed ulcer-like projection (ULP) in 21 patients (84%), which was consistent with surgical findings. One patient (4%) with preoperative cardiopulmonary arrest in the S group died on the 5th postoperative day from cerebral infarction. In the medical group, 18 patients (86%) completed rehabilitation and were discharged. However, 14% required surgical conversion during initial medical treatment, and 19% underwent surgical intervention after discharge due to various factors. Re-canalization occurred in 2 cases, enlargement of false lumen in 2 cases, enlargement of ULP in 1 case, new tear in the aortic root in 1 case, and enlargement of aortic root in 1 case. The median duration to surgical intervention was 38 days (5-330 days), all cases were within 1 year. The range of replacement was AR in 1 case, PAR in 2 cases, TAR+ frozen elephant trunk in 2 cases, and ARR in 2 cases. There were 6 late deaths in the S group and none in the M group. Kaplan-Meier curves showed that the overall survival rate of the S group was 96% at 1 year and 70% at 5 years, which was significantly lower than that of the M group (P=0.016). Among patients in the M group who required surgical intervention after medical treatment, the initial aortic diameter of the ascending aorta was significantly larger than patient without surgical intervention (47.7±7.5mm vs 42.3±4.6mm, P<0.05) and the reduction rate of false lumen diameter was significantly smaller (-41.1±35.8% vs +0.1±30.5%, P=0 .017).
Conclusions: As the initial treatment of ATAIMH, the course of medical treatment followed by guidelines was excellent. Close CT monitoring during the acute phase is crucial ,.Surgical intervention, considering patient background and condition, can significantly improve prognosis upon exacerbation despite initial medical management.

Authors
Shuji Setozaki (1), Hiroshi Tsuneyoshi (1)
Institutions
(1) Shizuoka General Hospital, Japan, Shizuoka

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