Treatment Strategy of Intramural Hematoma
Patients with uncomplicated IMHBs received medical therapy to control
their pain (intravenous opiate analgesia), heart rate (less than 80
beats per minute), and blood pressure (systolic blood pressure between
100 and 120 mmHg) [1] .
The acute phase was defined as the
first fourteen days from the onset of IMHB, and the disease was
considered stable after an uneventful fourteen days (patient was
discharged) [1] . Electrocardiographic-triggered CTA (GE
Healthcare, Milwaukee, WI) was performed at least twice during the acute
phase (once on admission and once before discharge) in patient without
disease progression and with well-controlled blood pressure, heart rate
and pain; in eventful cases (uncontrollable back pain combined with
hemodynamic instability), CTA examinations were adjusted accordingly[1] . The patients were followed clinically according to
standard surveillance protocols [1] [15-17] . During the
follow-up, CTA was also performed at 1, 3, 6, and 12 months and then
annually during the extended follow-up. Disease progression was defined
as increased pleural effusion, hematoma thickening (thickness ≥10 mm),
development of an aortic pseudoaneurysm, aortic dissection or signs of
aortic rupture. Under the following situations, the patients would
receive TEVAR treatment: during the acute phase, the expansion of the
IMH and the development of pseudoaneurysms despite medical therapy, the
disruption of intimal tears on CTA examinations with contrast
enhancement, and signs of aortic rupture (uncontrollable back pain
combined with a precipitous decrease in blood pressure); and during the
chronic phase, the development of aortic dissection, the rapid growth of
the ULP or aortic diameters (>5 mm/year), maximum aorta
diameter > 55 mm, or signs of aortic rupture[1] . The diameter of the stent graft was based on the
diameter of the proximal attachment site with no more than a 10%
oversize.
At
least 1 week of medical therapy (if possible) was employed to provide
the initially fragile acute-stage membrane with time to stabilize and
become more fibrotic than it was before TEVAR [15] .
Preoperative or concomitant arch reconstructive methods were also
applied, including in situ laser fenestration technology, a sequential
debranching procedure and the chimney technique.