Secondary stent placement for sealing distal tears in aortic intramural hematoma and enhancing distal aortic remodeling: A retrospective study in a single center_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHEN Bailang , WANG Zanxin , ZHUANG Xianmian , LIU Haibing ,  WEI Minxin

Department of Cardiovascular Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, 518053, Guangdong, P. R. China;

Corresponding author：

WEI Minxin, Email: weimx@hku-szh.org

Keywords：

Staging reintervention; intramural hematoma; distal aortic remodeling; entry tear

DOI：

10.7507/1007-4848.202406074

Video：

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Objective To assess the clinical efficacy of endovascular treatment in the second stage for patients with progression to local or full-length dissection-like changes at the distal aorta following initial surgery for aortic intramural hematoma. Methods Between July 2020 and December 2022, patients with aortic intramural hematoma were treated initially for proximal lesions. During follow-up, if the distal aortic hematoma was not resorbed and entry tears were identified with progression to local or full-length dissection-like changes and possible focal contrast enhancement, and the patients undergoing a second-stage stent intervention were retrospectively collected. Initial surgeries included total aortic arch replacement or thoracic endovascular aortic repair (TEVAR) targeting the proximal entry tear. In the secondary stage, stents were strategically placed in three delineated regions of the distal aorta to seal the entry tears, promote hematoma resorption, and induce thrombosis of the false lumen. Results A total of 18 patients were collected, including 15 males and 3 females with a mean age of 53.5±10.6 years, ranging from 39 to 76 years. All patients achieved procedural success, yielding a technical success rate of 100%. Intraoperative and postoperative imaging confirmed effective sealing of the distal entry tears without stent leakage, visceral branch stenosis, or occlusion, and there were no serious complications such as perioperative cerebral infarction, paraplegia, or organ ischemia. Follow-up assessments showed complete thrombosis and disappearance of the false lumen in all patients. Conclusion In patients with unresolved entry tears and dissection-like changes post-initial surgery for aortic intramural hematoma, secondary stent placement effectively seals these tears, promotes thrombosis and resorption of the hematoma, and improves endovascular remodeling of the aorta, demonstrating favorable short- to medium-term outcomes.

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6.	Jiang X, Pan T, Liu Y, et al. Prognostic implications of initial focal contrast enhancement in acute type B intramural hematoma. J Am Coll Cardiol, 2024, 83(4): 503-513.
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11.	周旻, 符伟国. Stanford B型主动脉夹层诊断和治疗中国专家共识(2022版). 中国血管外科杂志(电子版), 2022, 14(2): 119-130.
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13.	Chen B, Zhang R, Liu H, et al. Efficacy of endovascular repair in the treatment of retrograde ascending aortic intramural haematoma. J Cardiothorac Surg, 2023, 18(1): 130.
14.	Kärkkäinen JM, Tenorio ER, Pather K, et al. Outcomes of small renal artery targets in patients treated by fenestrated-branched endovascular aortic repair. Eur J Vasc Endovasc Surg, 2020, 59(6): 910-917.
15.	孙岩, 王玉涛, 张十一, 等. 3D打印辅助开窗支架及分支支架技术治疗累及内脏动脉区胸腹主动脉瘤的效果分析. 中国胸心血管外科临床杂志, 2022, 29(1): 90-94.
16.	Gallitto E, Gargiulo M, Freyrie A, et al. Endovascular repair of thoracoabdominal aortic aneurysm in high-surgical risk patients: Fenestrated and branched endografts. Ann Vasc Surg, 2017, 40: 170-177.
17.	Ultee KHJ, Zettervall SL, Soden PA, et al. Perioperative outcome of endovascular repair for complex abdominal aortic aneurysms. J Vasc Surg, 2017, 65(6): 1567-1575.
18.	Wang R, Kan Y, Yang M, et al. Clinical results and aortic remodeling after endovascular treatment for complicated type B aortic dissection with the "fabulous" stent system. Front Cardiovasc Med, 2022, 9: 817675.
19.	Żołnierczuk M, Miśkiewicz M, Paduch J, et al. Questionable long-term results of the extended provisional extension to induce complete attachment (E-PETTICOAT) technique in the management of chronic type B aortic dissection. Ann Vasc Surg, 2023, 89: 210-215.

1. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(41): 2873-2926.
2. Sorber R, Hicks CW. Diagnosis and management of acute aortic syndromes: Dissection, penetrating aortic ulcer, and intramural hematoma. Curr Cardiol Rep, 2022, 24(3): 209-216.
3. Vacirca A, Dias Neto M, Baghbani-Oskouei A, et al. Timing of intervention for aortic intramural hematoma. Ann Vasc Surg, 2023, 94: 14-21.
4. Boufi M, Patterson BO, Grima MJ, et al. Systematic review of reintervention after thoracic endovascular repair for chronic type B dissection. Ann Thorac Surg, 2017, 103(6): 1992-2004.
5. Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines. Circulation, 2022, 146(24): e334-e482.
6. Jiang X, Pan T, Liu Y, et al. Prognostic implications of initial focal contrast enhancement in acute type B intramural hematoma. J Am Coll Cardiol, 2024, 83(4): 503-513.
7. Osada H, Kyogoku M, Ishidou M, et al. Aortic dissection in the outer third of the media: What is the role of the vasa vasorum in the triggering process? Eur J Cardiothorac Surg, 2013, 43(3): e82-e88.
8. Chin AS, Willemink MJ, Kino A, et al. Acute limited intimal tears of the thoracic aorta. J Am Coll Cardiol, 2018, 71(24): 2773-2785.
9. Shao T, Bornak A, Kang N. Penetrating aortic ulcer and aortic intramural hematoma: Treatment strategy. Vascular, 2023, 31(6): 1086-1093.
10. Estrera AL, Sandhu HK, Leake SS, et al. Early and late outcomes of acute type A aortic dissection with intramural hematoma. J Thorac Cardiovasc Surg, 2015, 149(1): 137-142.
11. 周旻, 符伟国. Stanford B型主动脉夹层诊断和治疗中国专家共识(2022版). 中国血管外科杂志(电子版), 2022, 14(2): 119-130.
12. 徐乐吟, 来志超, 邵江, 等. Stanford B型主动脉夹层远端破口的腔内治疗策略. 中华外科杂志, 2021, 59(8): 711-715.
13. Chen B, Zhang R, Liu H, et al. Efficacy of endovascular repair in the treatment of retrograde ascending aortic intramural haematoma. J Cardiothorac Surg, 2023, 18(1): 130.
14. Kärkkäinen JM, Tenorio ER, Pather K, et al. Outcomes of small renal artery targets in patients treated by fenestrated-branched endovascular aortic repair. Eur J Vasc Endovasc Surg, 2020, 59(6): 910-917.
15. 孙岩, 王玉涛, 张十一, 等. 3D打印辅助开窗支架及分支支架技术治疗累及内脏动脉区胸腹主动脉瘤的效果分析. 中国胸心血管外科临床杂志, 2022, 29(1): 90-94.
16. Gallitto E, Gargiulo M, Freyrie A, et al. Endovascular repair of thoracoabdominal aortic aneurysm in high-surgical risk patients: Fenestrated and branched endografts. Ann Vasc Surg, 2017, 40: 170-177.
17. Ultee KHJ, Zettervall SL, Soden PA, et al. Perioperative outcome of endovascular repair for complex abdominal aortic aneurysms. J Vasc Surg, 2017, 65(6): 1567-1575.
18. Wang R, Kan Y, Yang M, et al. Clinical results and aortic remodeling after endovascular treatment for complicated type B aortic dissection with the "fabulous" stent system. Front Cardiovasc Med, 2022, 9: 817675.
19. Żołnierczuk M, Miśkiewicz M, Paduch J, et al. Questionable long-term results of the extended provisional extension to induce complete attachment (E-PETTICOAT) technique in the management of chronic type B aortic dissection. Ann Vasc Surg, 2023, 89: 210-215.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesSecondary stent placement for sealing distal tears in aortic intramural hematoma and enhancing distal aortic remodeling: A retrospective study in a single center

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