Jae‐Kwan Song

BACKGROUND: The proper treatment option for patients with type A intramural hematoma (IMH), a variant form of classic aortic dissection (AD), remains controversial. We assessed the outcome of our institutional policy of urgent surgery for unstable patients and initial medical treatment for stable patients with surgery in cases with complications. METHODS AND RESULTS: Among 357 consecutive patients with type A acute aortic syndrome, 101 (28.3%) had IMH and 256 had AD. Urgent operations were performed in 224 patients with AD (87.5%) and 16 with unstable IMH (15.8%; P<0.001). The remaining 85 stable IMH patients received initial medical treatment, and adverse clinical events developed in 31 patients (36.5%) within 6 months, which included development of AD (n=25), delayed surgery (n=25), or death (n=6). Initial aorta diameter and hematoma thickness were independent predictors for development of these events, and the best cutoff values were 55 and 16 mm, respectively. The overall hospital mortality was lower in IMH patients than in AD patients (7.9% [8/101] versus 17.2% [44/256]; P=0.0296) and was comparable to that of surgically treated AD patients (7.9% versus 10.7% [24/224]; P=0.56). The 1-, 2-, and 3-year survival rates of IMH patients were 87.6+/-3.6%, 84.9+/-3.7%, and 83.1+/-4.1%, respectively. There was no statistical difference of overall survival rates between patients with IMH and surgically treated AD patients (P=0.787). CONCLUSIONS: The clinical outcome of IMH patients receiving treatment by our policy was comparable to that of surgically treated AD patients. However, adverse clinical events were not uncommon with medical treatment alone, and initial aorta diameter and hematoma thickness may identify patients who might benefit from urgent surgery.

BACKGROUND: Optimal management strategy of acute aortic dissection (AD) with retrograde extension from entry tear in the descending aorta into the ascending aorta remains undetermined. METHODS AND RESULTS: Of the 538 patients who were diagnosed as having acute AD from 1999 through 2011, 49 patients (37 men; 52.5±13.1 years) were identified as having entry tear in the descending aorta with retrograde extension of AD into the ascending aorta. Sixteen patients who were clinically stable with thrombosed false lumen in the ascending aorta were treated medically (MED group), whereas 33 patients underwent aortic replacement (SURG group) on an intention-to-treat basis. In the MED group, 1 patient was converted to urgent aortic surgery and 2 patients underwent endovascular stent grafting in the descending aorta during the initial hospitalization. The early (30-day or in-hospital) mortality rates were 0% and 9.1% in the MED and SURG group, respectively (P=0.54). Follow-up was complete in all patients (median, 61.4 months; Q1-Q3, 28.2-99.1 months). The 5-year 100% survival rate in the MED group was higher than that in the SURG group (81.2±7.0%; P=0.080), in the surgically treated patients with antegrade type A AD (74.5±2.8%; P=0.038), and in the patients with type B AD (75.3±3.3%; P=0.045). Aortic event-free survival at 5 years was 52.7±14.8% and 69.6±8.0% in the MED and SURG groups, respectively (P=0.98). CONCLUSIONS: Patients with acute retrograde type A AD showed a more favorable prognosis than patients with antegrade AD. In selected patients with retrograde type A AD, excellent outcomes could be achieved with initial medical management combined with timely interventions.