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Predictors of Intervention in Acute Type B Aortic Penetrating Ulcer and Intramural Hematoma

  • Author Footnotes
    # Shared first authorship since the authors equally contributed
    Michele Piazza
    Footnotes
    # Shared first authorship since the authors equally contributed
    Affiliations
    Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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  • Author Footnotes
    # Shared first authorship since the authors equally contributed
    Francesco Squizzato
    Correspondence
    Address reprint requests to Francesco Squizzato, MD, Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy.
    Footnotes
    # Shared first authorship since the authors equally contributed
    Affiliations
    Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
    Search for articles by this author
  • Luca Porcellato
    Affiliations
    Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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  • Eugenia Casali
    Affiliations
    Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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  • Franco Grego
    Affiliations
    Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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  • Michele Antonello
    Affiliations
    Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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  • Author Footnotes
    # Shared first authorship since the authors equally contributed
      We aimed to investigate predictors of intervention of acute type B aortic penetrating ulcer (PAU) and intramural hematoma (IMH). We conducted a retrospective chart review of all patients admitted for acute type B PAU or IMH in a tertiary referral hospital. Indications to intervention were “complicated” (rupture, impending rupture, malperfusion) or “high risk for unfavorable outcome” (refractory hypertension and/or pain despite best medical treatment, morphologic aortic evolution, transition to a new aortic syndrome, or increase in IMH/PAU depth >5 mm) during the acute/subacute phase. The primary outcomes were overall mortality, aortic-related mortality, and freedom from intervention. Time-dependent outcomes were estimated with Kaplan-Meier curves. Cox proportional hazards models were used to identify predictors of intervention and mortality. There were 54 acute aortic syndromes, 37 PAUs and 17 IMHs. Mean age was 69 ± 14 years and 33 patients (62.2%) were male. Six (11.5%) patients had complicated aortic syndromes and underwent urgent repair. Two (3.7%) additional patients developed an impending rupture during the acute phase. Eleven (21.1%) patients were classified as at “high risk” during the initial hospitalization. Overall, 22 (40.7%) patients required an aortic intervention during the initial admission (n = 16, 72.7% during the acute phase; n = 6, 27.3% during the subacute phase). In-hospital mortality was 5.5% (1 PAU and 2 IMH), and was aorta-related in all cases. For IMH, disease extension in >3 aortic zones (HR 1.94, 95%CI 1.17–32.6; p = 0.038) and presence of ulcer-like projections (ULPs) (HR 1.23, 95%CI 1.02–9.41; p = 0.042) were associated with the need for intervention. There were no aortic-related deaths or intervention during the chronic phase. PAU width >20 mm (HR 1.68, 95%CI 1.07–16.08; p = 0.014), PAU depth >15 mm (HR 6.74, 95%CI 1.31–34.18; p = 021), PAU depth/total aortic diameter >0.3 (HR 4.31, 95%CI 1.17–20.32; p = 0.043), and location at the level of the paravisceral aorta (HR 2.24, 95%CI 1.23–4.70; p = 0.035) were significantly associated with need for intervention. Six additional (16.2%) PAUs required intervention during the chronic phase owing to PAU growth. Maximum aortic diameter >35 mm was significantly associated with intervention (HR 1.45, 95%CI 1.00–2.32; p = 0.037). Acute symptomatic type B IMHs and PAUs are characterized by a high risk of complications during the first month from presentation. Morphologic features associated with intervention were IMH with ULPs or extension in more than 3 aortic zones, as well as PAUs with depth>15 mm, width >20 mm, or depth/aortic diameter ratio>0.3. A strict follow-up protocol or consideration for early intervention within 30 days from presentation should be taken into account for these high-risk patients. During the chronic phase imaging follow-up is particularly important for PAUs in order to identify progression to saccular aneurysms.

      Graphical Abstract

      Keywords

      Abbreviations:

      AAS (Acute Aortic Syndrome), IMH (Intramural Hematoma), PAU (Penetrating Aortic Ulcer), ULP (Ulcer-like Projection)
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