IMH/Penetrating Aortic Ulcers/ Saccular Aneurysms: How to manage and when to intervene

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1 IMH/Penetrating Aortic Ulcers/ Saccular Aneurysms: How to manage and when to intervene UCSF Vascular Surgery Symposium 2018 Sukgu M Han, MD, MS Assistant Professor of Clinical Surgery Co-director, Comprehensive Aortic Center Division of Vascular Sugery and Endovascular Therapy Keck Medical Center of USC Sukgu.han@med.usc.edu

2 DISCLOSURES Cook Medical: Consultant, Proctor for TX2, Zenith, Alpha, Zenith Fenestrated Gore & Associates: Consultant 2

3 What is the diagnosis? 1. PAU with associated IMH 2. Saccular Aneurysm 3. Focal Dissection 4. IMH with associated ULP 3

4 Aortic Dissection Penetrating Aortic Ulcer Intramural Hematoma Saccular Aneurysm 4

5 Intramural Hematoma (IMH) Hematoma within the media without open communiation to the lumen via intimal flap Pathophysiology: Rupture of vasa vasorum, intimomedial tear (vs thrombosed false lumen) Similar presentation as aortic dissection Rare malperfusion 5~30% of acute aortic syndromes Type A/B IMH 5

6 Imaging for IMH 6

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9 Natural Course of IMH Regression (10~40%) Progression to aortic rupture (20~45%) Progression to aortic dissection (28~47%) Regional variations in reported risks Asia: more benign? Bosson et al. E Heart J

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11 Indications for Repair Type A Persistent/Recurrent pain despite optimal anti-impulse therapy Refractory HTN Rapid growth High risk features 11

12 Predictors of Adverse Aortic Event in Medically Managed Type B IMH Initial aortic diameter > 40mm Thickness of IMH > 10mm Development of ULP > 10~15mm Age > 70 y/o Pleural effusion 12

13 Case 65 M with sudden chest pain radiating to back PMH/PSH: HTN Fam Hx: no aortopathy 13

14 Treatment Options? 1. Anti-impulse Therapy 2. TEVAR 3. Open Repair 14

15 Follow Up CTA in 2 weeks 15

16 Treatment Options? 1. Anti-impulse Therapy 2. Zone 3 TEVAR 3. Zone 2 TEVAR 4. Zone 1 TEVAR 5. Total Arch Repair with (Frozen) Elephant Trunk 16

17 Zone 2 TEVAR + CCA-LSCA BPG 17

18 Post TEVAR CTA 18

19 TEVAR for IMH Perioperative mortality after TEVAR in acute IMH ~ 4.6% (vs Open Repair of acute IMH ~ 16%) Endoleak/stent-induced tear Pseudoaneurysms at ends of the stent graft Evangelista et al. Eur J Cardiothorac Surg,

20 Endovascular Stent-graft Management of Aortic Intramural Hematomas Valérie Monnin-Bares, MD, Frédéric Thony, MD, Mathieu Rodiere, MD, Vincent Bach, MD, Rachid Hacini, MD, Dominique Blin, PhD, and Gilbert Ferretti, PhD 15 TEVAR performed for type A, and B IMH All cases with identifiable intimal flap Targeted lesion= intimal flap Shortest stent grafts used Landing in descending even in type A IMH 20

21 Technical considerations for TEVAR for IMH Conservative oversizing 10% Coverage of entire IMH may require extensive aorta coverage and coverage of aortic branches Proximal edge of the seal zone must be in healthy aorta (15mm length) Often requires left SCA coverage Risk of retrograde dissection 21

22 Penetrating Aortic Ulcer Erosion of mural atheroma, causing focal blood flow into the aortic wall without flap Associated IMH Older, more cardiovascular atherosclerotic comorbidities 22

23 When to intervene on PAU? Clinical or radiologic signs of rupture Persistent pain despite optimal medical treatment Large associated IMH > 11mm Total aortic diameter > 50mm Periaortic pleural effusion 23

24 TEVAR for PAU Perioperative mortality 7.2% (vs 16% in open repair) Access issues Associated IMH Evangelista et al. Eur J Cardiothorac Surg,

25 Summary IMH/PAU/Aortic Dissections can rapidly evolve Surgical repair first line therapy in type A IMH/ PAU Conservative management first line therapy in type B IMH/PAU with close surveillance! TEVAR with conservative landing zone 25