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Tevar For Management Of Type B Intramural Hematoma With Retrograde Arch Extension
Erin E. McIntosh, MD, Ryan Wahidi, MD, Varun Dalmia, MD, Fatima Mustansir, MD, Zachary Wanken, MD, John Westley Ohman, MD.
Washington University in St. Louis, Saint Louis, MO, USA.
OBJECTIVES: Aortic intramural hematoma (IMH) has an unpredictable clinical course depending on the extent of disease. Unless there are signs of aortic instability, type B IMH management involves ICU admission for impulse control, close monitoring of blood pressure, and patient symptoms. There are patients with mixed pathologies who have type B IMH with concomitant type A IMH, for whom the appropriate management remains unclear. In this case series, we examine our single-center experience with thoracic endovascular aortic repair (TEVAR) for this patient subset.
METHODS: We identified 65 patients between 2018-2024 that were treated at our institution for IMH. Of those, 7 patients had a type B IMH with ulcer-like projection with concomitant type A IMH, treated with TEVAR at the index hospitalization. IMH thickness and extent was examined and compared between pre-operative and post-operative CTA imaging studies to assess for resolution and positive aortic remodeling after TEVAR.
RESULTS: In our series, 5 patients had resolution of their type A IMH by 5 months, and as early as 3-5 weeks in 2 of those patients. The type B component of IMH had resolved in 5 patients by 10 months, and as early as 11-14 days in 2 patients. Four patients did not require any reintervention. Two patients required reintervention - one 5 days post-op for proximal arch rupture and one for planned fenestrated repair of known thoracoabdominal aneurysm. One of the 7 patients was lost to follow up.
CONCLUSIONS: Early TEVAR for patients who present with type B IMH with ulcer-like projection with concomitant ascending or arch IMH, is an acceptable management strategy that helps promote favorable aortic remodeling.
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