经保守治疗A型主动脉壁内血肿的死亡相关危险因素分析

目的探讨保守治疗的A型主动脉壁内血肿(IMH)患者死亡的危险因素,为临床危险分层和治疗决策提供依据。方法回顾性搜集2009年9月至2018年6月在中国医学科学院阜外医院入院,首次CT检查中确诊为A型IMH且只接受药物治疗的患者,共130例。搜集患者的临床和影像资料并进行随访,随访终点为主动脉源性死亡,依据患者是否发生终点事件分为终点事件组(26例)和非终点事件组(104例)。分别采用独立样本t检验、非参数Mann-Whitney U检验、χ2检验或Fisher精确检验比较正态分布的连续变量、非正态分布的连续变量和分类变量的组间差异,并对随访结果作Cox回归分析及生存分析以确定独立危险因素。结果在基线CT资料中,主动脉最大管径(MAD)为(49.2±6.9)mm,最大血肿厚度(MTH)为11.0(8.5,13.2)mm。有溃疡样凸起(ULP)和壁内血池(IBP)征象的患者分别有56和30例,其中升主动脉ULP征象有36例,伴心包积液和胸腔积液的患者分别有51和50例。随访时间为1050(242,1949)d,随访期间有26例患者发生主动脉源性死亡。终点事件组患者与非终点事件组相比平均年龄和MAD更大(t=2.363、3.640,P=0.020、<0.001),有主动脉粥样硬化、ULP和心包积液的患者比例更高(χ2=5.275、6.596、9.325,P=0.022、0.010、0.002)。Cox回归多因素分析结果显示,主动脉粥样硬化[风险比(HR)=3.48,P=0.043]、ULP(HR=2.66,P=0.019)和心包积液(HR=2.49,P=0.030)是主动脉源性死亡的独立危险因素。结论对于保守治疗的A型IMH患者,主动脉粥样硬化、ULP及心包积液是后续发生主动脉源性死亡的独立预测因素,识别这些危险因素有助于进一步的危险分层和治疗决策。     

Newly developed ulcer-like projection (ULP) in aortic intramural haematoma on follow-up CT: is it different from the ULP seen on the initial CT?

AIM: To show whether the clinical and radiological features of newly developed ulcer-like projections (nULPs) in an aortic intramural haematoma (IMH) on follow-up computed tomography (CT) images, are different from those of the initial ULPs (iULPs) on the initial CT images. MATERIALS AND METHODS: A review of the radiological database revealed 98 patients with IMH with at least two follow-up CT examinations with a follow-up period of more than 1 month. The patients were divided into four groups: patients without iULPs or nULPs throughout the follow-up periods (group A); patients with iULPs on the initial CT images (group B); patients with nULPs on follow-up CT images but without iULPs on the initial CT images (group C); and patients with both iULPs and nULPs (group D). The type of IMH, aortic diameter, thickness of the haematoma, and complications were analysed. The clinical and CT findings and complications in the four groups were compared. RESULTS: Forty-two patients had no iULPs nor nULPs (group A); 27 patients had 45 iULPs on the initial CT images (group B); 16 patients had 17 nULPs on follow-up CT images without any ULP on the initial CT images (group C); and 21 nULPs developed in 13 patients with iULPs (group D). There was no significant difference in the demographic or initial CT findings in the four groups. There was no statistical difference in the incidence of complications between groups B (59.3%), group C (62.5%), and group D (69.2%; p=0.830), but there was a significant difference in the incidence of complications between the patients without any ULPs (21.5% in group A) and those with ULPs (62.5% in groups B, C, and D). CONCLUSION: There were no significant differences in the CT findings or complications between the patients with iULPs and nULPs. Regardless of the developing time of the ULPs, the incidence of complications of IMH in patients with ULPs was higher than that in those without ULPs. Careful and regular follow-up CT examinations are needed for patients with ULPs.     

急性壁间血肿合并穿透性主动脉溃疡的MSCTA诊断

目的评价多层螺旋CT血管造影(MSCTA)技术在急性壁间血肿合并穿透性溃疡的临床应用价值。方法对20例急性壁间血肿合并穿透性溃疡患者行MSCTA检查,结合二维和三维重建技术进行图像分析。结果按照Stanford分型,A型:5例,B型:15例。所有病例均未显示真假腔及撕裂内膜片,均合并主动脉穿透性溃疡。主动脉壁间血肿(aortic intramural hematoma,IMH)表现为主动脉壁"环"形或"新月"形增厚,伴钙化内膜内移12例,胸腔积液8例,心包积液4例。穿透性溃疡20例共28个病灶,表现为主动脉壁上的溃疡样突起(ulcerlike pro-jection,ULP),其中穿透性主动脉粥样硬化性溃疡(penetrating atherosclerotic ulcer,PAU)14例共22个(79%)病灶,6个(21%)ULP病灶均单发。结论 MSCTA是一种有效、无创的诊断急性壁间血肿合并穿透性溃疡的检查方法,能为临床诊断和治疗提供重要信息。     

Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Associated with Retrograde Type A Intramural Hematoma

PurposeTo evaluate feasibility and efficacy of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) associated with retrograde type A intramural hematoma (IMH).Materials and MethodsFrom April 2013 to January 2017, 15 consecutive patients with TBAD associated with retrograde type A IMH who underwent TEVAR were reviewed retrospectively. There was no cardiac tamponade, aortic regurgitation, involvement of coronary artery, or sign of cerebral ischemia in these patients. Enhanced CT was used in 4 patients to diagnose malperfusion of abdominal visceral arteries or lower extremity artery and underwent emergent TEVAR. For the remaining 11 patients, repeated enhanced CT after initial medical treatment within 24 hours from onset of pain showed expansion of IMH in 8 patients or presence of periaortic hematoma in 3 patients. Delayed TEVAR was scheduled for these cases.ResultsSuccessful deployment of the stent graft was achieved in all patients. There were no severe postoperative complications, such as retrograde type A aortic dissection or aortic rupture. Sudden death occurred in 1 patient 3 months after the procedure. Thrombosis of the false lumen, shrinkage of the diameter of the aorta, and complete absorption of the IMH were observed in the remaining patients at a mean follow-up of 19.8 months ± 6.57.ConclusionsTEVAR for treatment of TBAD with retrograde type A IMH is feasible and effective. It represents a treatment option for patients with TBAD associated with type A IMH with a proximal entry tear located in the descending aorta.     

New development of an ulcerlike projection in aortic intramural hematoma: CT evaluation

PURPOSE: To investigate the natural history and predictors of progression of a newly developed ulcerlike projection in patients with an aortic intramural hematoma. MATERIALS AND METHODS: Serial computed tomographic (CT) findings in 52 patients with intramural hematoma were reviewed. Sixteen patients had Stanford type A intramural hematoma, and 36 had Stanford type B. Diagnosis of intramural hematoma was established with CT. Regular follow-up studies were performed every week during the 1st month and two or three times a year after the 2nd month. The presence or absence of an ulcerlike projection, diameter and progression of the projection, and aortic diameter were evaluated. Relationships among ulcerlike projections, clinical data, and CT findings were analyzed. RESULTS: In 17 (33%) of the 52 patients, 17 ulcerlike projections were newly identified during the follow-up period. Patients with type A intramural hematoma had a significantly higher frequency of new development of ulcerlike projection than that of patients with type B intramural hematoma (P =.002). In 17 patients with new development of ulcerlike projection, 12 (70%) of 17 projections progressed to complications such as enlargement (n = 10) or progression to overt aortic dissection (n = 2). One of 10 enlarged projections progressed to rupture. A significant predictor of progression of ulcerlike projection was based on location from the ascending aorta to the aortic arch with the use of univariate (P =.009) and multivariate Cox (P =.018) regression analyses. CONCLUSION: The location of ulcerlike projections is the principal predictor of progression, and careful follow-up study is needed for patients with an ulcerlike projection located from the ascending aorta to the aortic arch.     

Extensive Iatrogenic Aortic Dissection During Renal Angioplasty: Successful Treatment with a Covered Stent-Graft

An extensive iatrogenic aortic type B dissection during percutaneous transluminal renal angioplasty (PTRA) for bilateral renal artery stenosis was treated with a covered stent placed in the right renal artery. Control angiography confirmed closure of the entry. Postprocedural CT demonstrated a thick intramural hematoma (IMH) up to the left subclavian artery. CT follow-up at 8 months showed an almost complete resorption of the IMH. While medical treatment is the standard therapy for type B dissections, closure of the intimal tear with a covered stent may be an additional option in extensive cases during PTRA.     

CT Findings of Ruptured Intramural Hematoma of the Aorta Extending Along the Pulmonary Artery

Mediastinal hematoma extending along the pulmonary artery is a rare complication of Stanford type A classic (double-barreled) aortic dissection. Rupture from the posterior aspect of the aortic root penetrates the shared adventitia of the aorta and pulmonary artery. From this location, hematoma can spread along the adventitial planes of the pulmonary arteries out into the lungs. We report a case of ruptured intramural hematoma of the aorta (IMH) extending along the pulmonary artery. To our knowledge, this finding in patients with IMH has not been reported in the literature.     

Acute non-opacified dissection of the ascending thoracic aorta--significance of retrograde dissection and re-dissection]

Thirteen cases of acute aortic dissection with non-opacified false lumen of the ascending aorta were examined by CT and other imaging modalities. On the basis of the initial CT findings, these cases were classified into two types; one was pure non-opacified dissection not associated with opacified false lumen (Type N, n = 7), the other was non-opacified dissection of the ascending aorta associated with opacified false lumen of the following aorta (Type N+O, n = 6). On examining the relation between the entry site and the false lumen in Type N+O, the dissection of the ascending aorta was considered to be retrograde. Retrograde dissection seemed to be an important factor in the development of the non-opacified dissection of the ascending aorta. During the follow-up period, re-dissection in the ascending aorta occurred in four of the 13 cases (Type N = 3, Type N+O = 1). The re-dissection occurred within the first four weeks in all of them, and the diagnosis of re-dissection was possible at its early stage. In one case, ulcerlike projection (ULP) was detected by aortography. In another case, ULP was identified by cine-MR imaging. Contrast CT also revealed enlargement and small opacification of the false lumen. In two other cases, similar CT findings were observed. Three of the four patients recovered by surgical treatment. One died the day after the diagnosis of re-dissection. Early diagnosis and earliest possible surgical intervention for re-dissection were considered necessary to save the patients with re-dissected false lumen in the ascending aorta. Close observations with several imaging modalities, mainly CT examination, should be paid in the patients with non-opacified dissection of the ascending aorta for at least four weeks after the onset of dissection.     

Aortic intramural hematoma: Review of high-risk imaging features

Aortic intramural hematoma is among the spectrum of pathologies that comprises acute aortic syndrome and carries a risk of progression to aortic dissection, aneurysm, rupture, and other complications. Evaluation by CT can identify imaging features associated with higher risk of complications. Ulcer-like projections, enlarged aortic diameter, increased hematoma thickness, and Stanford type A classification are associated with progression to complications. The significance of intramural blood pools within the hematoma and associated pleural/pericardial effusions is less certain. Detailed evaluation of intramural hematoma with CT can provide critical prognostic information with implications for patient management.     

Predictive value of small ulcers in the evolution of acute type B intramural hematoma

Objective

To assess the long-term evolution and predictive factors of type B intramural hematoma (IMH).

Material and methods

34 patients (33 men), mean age: 67 years (47–87) diagnosed with type B IMH by computed tomography (CT) and followed up clinically and by CT yearly. Mean follow-up was 5.9 years (2–13 years). Two evolution patterns were considered: (a) regression and (b) progression. Clinical and imaging variables were analyzed for assessing their predictor values.

Results

Evolution at one year was to regression in 56% and to progression in 44% of cases. There were no association among age, sex, other aortic abnormalities, presence of atherosclerotic disease or blood pressure, initial maximum aortic diameter, indexed maximum aortic diameter, IMH thickness or length, presence or absence of mediastinal hematoma and the evolution of type B IMH. Ten patients had small aortic ulcers in the acute phase. The presence of ulcers was related with progression of IMH. No differences were observed in evolution between the control at first year and the last control.

Conclusions

The presence of small ulcers is a strong predictor of evolution in acute type B IMH. In addition, the regression group remains completely stable after the first year of evolution.     

Complications of endovascular repair for thoracic and abdominal aortic aneurysm: an imaging spectrum.

Endovascular stent-graft implantation is an alternative to conventional open surgery for the treatment of aortic aneurysm. Forty-nine consecutive patients with aortic aneurysm (thoracic, n = 17; infrarenal, n = 32) were treated with endovascular stent-graft implantation. Complications occurred in 25 patients (two patients had two complications): endoleak (n = 13), graft thrombosis (n = 5), graft kinking (n = 2), pseudoaneurysm caused by graft infection (n = 1), graft occlusion (n = 1), shower embolism (n = 1), perforation of mural thrombus by means of inadvertent penetration of delivery system (n = 1), colon necrosis (n = 1), aortic dissection (n = 1), and hematoma at the arteriotomy site (n = 1). Imaging findings were analyzed for spiral computed tomography, plain abdominal radiography, transesophageal echocardiography, and digital subtraction angiography. Since some of these complications are fatal, radiologists need to instantly and accurately recognize them. Awareness and understanding of possible complications should help ensure a safe, successful procedure.     

Thoracic involvement of type A aortic dissection and intramural hematoma: diagnostic accuracy--comparison of emergency helical CT and surgical findings

PURPOSE: To assess the accuracy of various findings at emergency helical computed tomography (CT) for the evaluation of thoracic involvement of type A aortic dissection (AD) and type A intramural hematoma (IMH) and to compare these findings with those at surgical confirmation. MATERIALS AND METHODS: Fifty-seven patients with acute chest pain underwent emergency helical CT and subsequent surgery for type A AD or IMH. Patients in whom AD or IMH was detected in three segments of the thoracic aorta or those in whom there was a site of any entry tear, arch branch vessel involvement, pericardial effusion, or aortic arch anomaly were examined at helical CT. Sensitivity, specificity, and accuracy of helical CT, along with 95% CIs, were calculated by using surgical confirmation as the reference standard. RESULTS: For the detection of AD or IMH of the thoracic aorta, the accuracy of helical CT was 100%. The sensitivity, specificity, and accuracy, respectively, were 82%, 100%, and 84% for an entry tear; 95%, 100%, and 98% for arch branch vessel involvement; and 83%, 100%, and 91% for pericardial effusion. These values were all 100% for aortic arch anomalies. CONCLUSION: Emergency helical CT of the thorax depicts findings that are highly accurate in the evaluation of acute type A AD and IMH.     

Aortic intramural hematoma: aspects with spiral computerized tomography

PURPOSE: To evaluate the signs of aortic intramural hematoma with helical CT and the diagnostic role of this technique in patients with this condition. MATERIAL AND METHODS: We reviewed the CT findings of 396 patients submitted to emergency examinations for suspected aortic dissection from 1995 to 1999. Only 18 patients (6 women and 12 men) had CT signs of aortic intramural hematoma. Helical CT studies were carried out with the following parameters: slice thickness 10 mm, reconstruction index 10, feed 1.5 mm, conventional algorithm with minimum values of 130 kV and 125 mA. All patients were examined with dynamic contrast-enhanced CT, before and after a power injection of 130 mL ionic contrast material. We studied: hematoma localization and longitudinal extension; thickness and density of aortic wall; presence and location of intimal calcifications; integrity of intimal wall; hemomediastinum and/or hemothorax. RESULTS: Aortic wall thickening appeared as a high density crescent-shaped area at baseline CT and had low density on enhanced images in all patients. Thickening was eccentric in 14/18 patients and concentric in 4/18 only; it always exceeded 4 mm. We found some intimal calcifications in 8 patients and hemothorax and/or hemomediastinum in 9 patients. A patient with type A hematoma died of cardiac tamponade a few hours after CT diagnosis. Six patients (5 type B and 1 type A) underwent anti-hypertensive treatment and radiological follow-up. Eleven patients (6 type A and 5 type B) underwent prosthesis replacement and 5 of them (3 type A and 2 type B) died of postoperative complications. In the 5 type B patients surgery was performed because of treatment-resistant pain and of the onset of ischemic complications to abdominal organs caused by involvement of the main collateral branches of the aorta. One patient with type A hematoma was submitted to drug treatment because it was judged unresectable. DISCUSSION AND CONCLUSIONS: Intramural hematoma of the aorta is a distinct pathological entity, which should not be confused with aortic dissection. The imaging techniques (TEE, CT, MRI) have an important role in the final diagnosis of aortic hematoma. Presently Helical CT and MR angiography are the main tools in the early diagnosis of this condition before the development of complications. In our experience helical CT, before and after the administration of contrast material, was accurate in identifying the hematoma localization and extension.     

Aortic growth rates in chronic aortic dissection

AIM: To determine and compare rates of descending aortic enlargement and complications in chronic aortic dissection with and without a proximal aortic graft. METHODS AND MATERIALS: Fifty-two patients with dissection involving the descending aorta and who had undergone at least two computed tomography (CT) examinations at our institution between November, 1993 and February, 2004 were identified, including 24 non-operated patients (four type A, 20 type B) and 28 operated patients (type A). CT examinations per patient ranged from two to 10, and follow-up ranged from 1-123 months (mean 49 months, median 38.5 months). On each CT image, the aortic short axis (SA), false lumen (FL), and true lumen (TL) diameters were measured at the longitudinal midpoint of the dissection and at the point of maximum aortic diameter. Complications were tabulated, including aortic rupture and aortic enlargement requiring surgery. RESULTS: For non-operated patients, the midpoint and maximum point SA, TL, and FL diameters increased significantly over time. For operated patients, the midpoint and maximum point SA and FL diameters increased significantly over time. In both groups, aortic enlargement was predominantly due to FL expansion. Diameter increases in non-operated patients were significantly larger than those in operated patients. The rate of change in aortic diameter was constant, regardless of aortic size. Four non-operated and six operated patients developed aortic complications. CONCLUSIONS: In patients with a dissection involving the descending thoracic aorta, the FL increased in diameter over time, at a constant rate, and to a greater degree in non-operated patients (mostly type B) compared with operated patients (all type A).     

Stanford type A aortic dissection with pulmonary arterial intramural hematoma and pulmonary hemorrhage

A rare complication of a Stanford type A aortic dissection is extension along the pulmonary arteries. We present a case that shows main and right pulmonary artery intramural hematoma and pulmonary hemorrhage in an 80-year-old woman who presented with a type A Stanford aortic dissection. The 11-month follow-up multidetector CT angiogram for this patient showed that the right pulmonary artery had become aneurysmal.     

Acute aortic syndrome—pitfalls on gated and non-gated CT scan

Acute aortic syndrome (AAS) is a life-threatening condition which includes aortic dissection (AD), penetrating aortic ulcer (PAU) and intramural hematoma (IMH). Multi-detector computed tomography (MDCT) plays a crucial role in the diagnosis of this condition and for further clinical follow-up. It is important for radiologists to be aware of common pitfalls in cardiac-gated and non-gated CT in diagnosing AAS. They should also be wary of common mimics of AAS which may make a significant difference towards management of these patients. In this review, we present from our practice some of the common pitfalls and mimics of AAS on MDCT.     

Helical CT angiography of stent-grafts in abdominal aortic aneurysms: morphologic changes and complications.

Transfemoral placement of an endovascular stent-graft is increasingly be-ing used as an alternative to surgical repair in the treatment of abdominal aortic aneurysm, especially in high-risk patients. However, complications frequently occur after stent-graft placement. Helical computed tomographic (CT) angiography is a fast, minimally invasive procedure that is quickly becoming the imaging modality of choice for assessment of these complications. Thirty-nine patients who were treated for abdominal aortic aneurysm with stent-graft placement underwent helical CT angiography at routinely scheduled follow-up intervals or whenever complications were suspected. The resulting images were evaluated for the presence, extent, and origin of endovascular leaks. In addition, the position, shape, and patency of the stent-grafts were assessed. Findings included both graft-related (n = 4) and non-graft-related (n = 3) leaks, thrombosis of a graft limb (n = 3), distal migration of the stent-graft (n = 5), angulation of bifurcated stent-grafts distal to the main graft (n = 6), shrinkage of the abdominal aortic aneurysm (n = 7), enlargement of the aneurysm with secondary graft-related leaks (n = 2), and an aortoduodenal fistula (n = 1). Helical CT angiography can depict complications that develop after treatment of abdominal aortic aneurysms with endovascular stent-grafts. Long-term follow-up is required to determine the full spectrum and frequency of complications that may develop after initially successful repair.     

覆膜支架治疗降胸主动脉瘤

目的评估覆膜支架治疗术治疗Stanford B型主动脉夹层和降主动脉瘤的安全性和近期疗效。方法2003年3月至2005年9月期间,共29例Stanford B型主动脉夹层和2例降胸主动脉瘤患者接受覆膜支架治疗术,所有患者均有高血压病史,其中急性发病27例.本组采用两种支架(Mdtronic Talent15例,上海微创Aegis 16例),术后采用CTA进行定期随访。结果所有支架均成功按预期定位释放,术后即刻DSA复查显示23例夹层患者近端破裂口完全封闭,2例降主动脉瘤也完全隔离,6例发现有内漏;术后7 d CTA复查发现16例假腔内完全血栓形成,12例近端假腔形成血栓,远端假腔仍开放。结论覆膜支架术治疗Stanford B型主动脉夹层和降主动脉瘤安全、有效,可替代外科手术。但覆膜支架术的确切长期疗效尚待进一步的大样本、前瞻性对照研究才能确定。     

多层螺旋CT血管成像在主动脉壁间血肿的临床应用

目的探讨主动脉壁间血肿（IMH）MSCT表现和诊断价值。方法10例经多层螺旋CT诊断及临床证实的IMH,男6例,女4例。使用16层螺旋CT检查,应用多平面重建、最大密度投影和容积成像等后处理方法显示壁间血肿及穿透性溃疡。结果10例IMH中,A型2例,B型8例,其中2例局限于胸主动脉,6例累及胸腹主动脉（止于肾动脉上方2例,髂总动脉分叉上方2例,2例累及双侧髂总动脉）。MSCT表现为主动脉腔内新月形或环形充盈缺损,内壁较光整,钙化内膜片内移及局灶性尖角样穿透溃疡形成,主动脉腔内无明确内膜片显示。结论多层螺旋CT能为主动脉壁间血肿的诊断、鉴别诊断和治疗提供准确的信息。     

Successful medical treatment of aortic intramural hematoma (Stanford type B) in a patient with aberrant right subclavian artery: A case report

Intramural Hematoma (IMH) forms part of the acute aortic syndrome, aortic dissection, and penetrating aortic ulcer. It is a life-threatening aortic disease that warrants prompt diagnosis and management. Like aortic dissections, it is classified using the Stanford classification system as type A (proximal to the origin of the left subclavian artery) and type B (distal to the origin of the left subclavian artery). Patients with type A IMH is generally managed surgically, and uncomplicated type B IMH is managed medically. The right subclavian artery arises typically from the brachiocephalic trunk. Aberrant right subclavian arteries (ARSA) are rare and derive directly from the aortic arch distal to the left subclavian artery. In this case report, a 73-year-old female presented with right-sided chest pain and shortness of breath. On examination, her heart rate was 100 bpm and blood Pressure was 185/85 and her ECG showed sinus rhythm. Following a CT scan, she was found to have a type B Aortic IMH with an ARSA. She was medically managed with vigorous blood pressure control. After a period of intravenous blood pressure treatment, she was treated with oral medication. Her subsequent CT scan showed that the hematoma was stable. She was followed up with MRI scanning 1 year later, which showed complete healing of the aorta with no changes in diameter. This case illustrates the importance of strict blood pressure management and follow-up imaging in patients presenting with type B IMH. It is important to monitor these patients regularly and where blood pressure control alone is not sufficient, further intervention may be required. Even though the complete resolution may be achieved as in this case, these patients will need to be kept under surveillance with repeated scans to monitor for any changes.