IFT10 - Outcomes of Acute Aortic Syndrome Due to Penetrating Aortic Ulcer and Intramural Hematoma in the Endovascular Era

Objectives: Management of acute aortic syndrome secondary to penetrating aortic ulcer (PAU) and intramural hematoma (IMH) remains challenging due to the paucity of data regarding its natural history and interventional outcomes. Endovascular technology has resulted in a paradigm shift in treatment, however medical management remains the standard of care. This study aimed to detail the short/long-term complications of symptomatic PAU/IMH in the endovascular era.

Methods: Institutional data on symptomatic PAU/IMH were gathered (2005-2020). Patients were treated medically initially aside from Type A IMH and ruptures. The primary outcome was the composite of recurrent symptoms, radiographic progression, intervention, rupture, and death from related or unknown cause. Factors associated with the primary outcome were determined using a Fine-gray model with death from an unrelated cause as a competing risk.

Results: There were 83 patients; 21 isolated symptomatic PAU, 30 with isolated IMH, and 32 with IMH and associated PAU or ulcer-like projection (ULP). Mean age at diagnosis was 71.7±10.9 years; 55.4% were female. Median clinical follow-up was 1.89 years (IQR: 0.33-4.50 years). IMH involved the ascending aorta in 24 (28.9%) of patients – 20 of whom underwent emergent repair. Three (3.6%) initially presented with rupture. Adverse outcomes included symptoms recurrence in 14 (16.9%) patients, radiographic progression to dissection or saccular aneurysm in 17 (20.5%), interventions (not including ascending aortic repairs for type A IMH) in 20 (24.1%) of patients (17 TEVAR, 1 EVAR, 1 frozen elephant trunk, 1 open repair), and rupture in 4 (4.8%) patients. Twenty-seven (32.5%) patients died during follow-up: 6 from IMH/treatment complications, 8 from an unknown cause, 13 from other causes. Thirteen (15.7%) patients had favorable aortic remodeling at a median of 0.49 years, postdiagnosis (IQR: 0.36-1.17). The 30-day, 1- and 5-year cumulative incidence of the primary outcome was 26.5% (95%CI: 16.9-37.0%), 44.9% (95%CI: 32.8-56.2%), and 57.5% (95%: 42.4-69.9%), respectively (Figure). IMH with PAU/ULP was associated with a significantly increased risk of the primary outcome compared to isolated IMH (SHR 2.21; 95% CI 1.09-4.50; p=0.027) and isolated PAU (SHR 3.58; 95% CI: 1.44-8.88; p=0.006).

Conclusions: Complications from symptomatic PAU and IMH are frequent, with intervention, recurrent symptoms, radiographic progression, rupture, or death affecting 25% of patients at 30-days post-diagnosis, and almost half of patients, 1-year post-diagnosis. Given the high rate of adverse events in this population, medical management alone may be inappropriate and investigation into a more aggressive interventional strategy may be warranted, especially in patients with IMH and associated PAU/ULP.