Clinical Efficacy Analysis Of Different Treatment Modalities And The Timing Of Surgery For Retrograde Type A Aortic Intermural Hematoma

Objective:There are limited studies on the surgical efficacy and timing of open surgery and thoracic endovascular aortic repair(TEVAR)in retrograde Type A aortic intermural hematoma(re-TAIMH).This study will evaluate and compare the effectiveness of open surgery and TEVAR in patients with re-TAIMH and further analyze the safety and efficacy of different surgical timing.Methods:50 patients diagnosed with re-TAIMH and treated surgically at the Second Affiliated Hospital of Nanchang University from 01,2017 to 07,2021 were collected.The patients were divided into open surgery group and TEVAR group according to the treatment they received;furthermore,according to the timing of surgical intervention,the open surgery group was split into emergency open surgery group(≤24h)and timely open surgery group(>24h),and the TEVAR group was divided into acute phase group(≤14d)and subacute phase group(>14d).The clinical data of the patients were retrospectively analyzed,including primary preoperative data,intraoperative data,postoperative complications,mortality,and aortic remodeling.Outcome:Of the 50 patients with re-TAIMH,40 were male,and 10 were female.27 patients performed open surgery,and 23 received TEVAR,with a median age of 60(50,67)and 52(47,74)years,respectively.Of whom 39 patients presented with ulcer-like projection(ULP)and 11 patients with a primary intimal tear in the distal left subclavian artery or descending aorta.In the preoperative data,significantly greater the ascending aortic diameter(50.17±3.07 vs.44.96±4.35 mm)and hematoma thickness [11.0(8.5,13.0)vs.9.5(8.5,10.0)mm] we found that the open surgery group(P<0.01 and P=0.025,respectively)than in the TEVAR group.And pericardial effusion,severe aortic regurgitation was significantly higher in the open surgery group.Postoperative follow-up CT results showed that open surgery ascending aortic diameter [26.0(26.0,28.0)vs.50.0(47.0,52.0)mm],hematoma thickness [0 vs.11.0(8.5,12.5)mm],and descending aortic diameter [28.0(26.0,30.0)vs.32.0(31.5,36.3)mm],hematoma thickness or false lumen diameter [2.0(0,3.0)vs.11.0(8.5,14.5)mm] were significantly reduced compared with preoperative CT results(P<0.001).Similarly,the ascending aortic diameter(38.74±3.03 vs.44.96±4.35 mm),hematoma thickness [1.0(0,2.0)vs.9.5(8.5,10.0)mm] and descending aortic diameter(29.35±4.02 vs.34.65±3.73 mm),hematoma thickness or false lumen diameter [3.0(0,5.0)vs.11.0(9.0,15.5)mm] were significantly reduced after TEVAR compared with preoperative CT results(P < 0.001).In addition,the overall postoperative mortality rates for the open surgery group and the TEVAR group were7.4% and 8.7%,respectively.In the open surgery group,14 patients underwent emergency surgery,13 patients were given timely surgery after new progressions.There was no statistically significant comparison of aortic diameter,hematoma thickness,or false lumen diameter after emergency surgery versus timely surgery.There were no deaths in timely open surgery,and only two patients experienced in-hospital death after emergency open surgery,no significant difference in mortality(P=0.22),and no adverse events of re-thoracotomy hemostasis occurred in either group.In addition,there was no significant difference in cumulative survival(P=0.165).8 and 15 patients performed TEVAR in the acute and subacute phases.The ascending aortic diameter,hematoma thickness,descending aortic hematoma,or false lumen diameter of postoperative in the subacute phase was significantly smaller than the acute phase group.In addition,the trend of change in ascending aortic hematoma thickness(P <0.001)and descending aortic hematoma or false lumen diameter(P<0.011)of postoperative in the subacute phase was more pronounced than in the acute phase.One patient experienced endoleak combined with paraplegia and cerebral hemorrhage after TEVAR in the acute phase,and two patients died during follow-up,whereas no postoperative endoleak,paraplegia,cerebrovascular accident,or death occurred in the subacute phase,and the cumulative survival rate was higher in patients who received TEVAR in the subacute phase compared with the acute phase(P=0.045).Conclusion:Open surgery and TEVAR in promoting aortic remodeling are effective for re-TAIMH,and both treatment modalities are safe and effective.For appropriately patients with re-TAIMH,TEVAR may be a safe and effective alternative treatment option to open surgery.It is also safe and feasible to perform timely open surgery for progressives compared to emergency open surgery.TEVAR is effective in both the acute and subacute phases,but TEVAR may be safer and aortic remodeling may be better in the subacute phase than the acute phase.