Secondary stent placement for sealing distal tears in aortic intramural hematoma and enhancing distal aortic remodeling: A retrospective study in a single center_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHEN Bailang , WANG Zanxin , ZHUANG Xianmian , LIU Haibing ,  WEI Minxin

Department of Cardiovascular Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, 518053, Guangdong, P. R. China;

Corresponding?author：

WEI Minxin, Email: weimx@hku-szh.org

Keywords：

Staging reintervention; aortic intramural hematoma; distal aortic remodeling; entry tear

DOI：

10.7507/1007-4848.202406074

Video：

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Objective To evaluate the clinical efficacy of second-stage endovascular therapy for patients with aortic intramural hematoma (IMH) who developed progression of the distal hematoma into dissection-like changes after an initial procedure. Methods A retrospective analysis was conducted on patients at the University of Hong Kong-Shenzhen Hospital from July 2020 to December 2022. These patients had previously undergone a first-stage procedure to treat the proximal lesion of an IMH. However, follow-up examinations revealed a persistent distal hematoma, the presence of a distal entry tear, and progression of the hematoma into localized or extensive dissection-like changes, which could be accompanied by localized contrast enhancement. These patients then underwent a second-stage stent-graft intervention. The initial procedures included open surgery with total aortic arch replacement or endovascular stent-graft placement to seal the proximal entry tear. In the second-stage procedure, the aorta was divided into three zones based on its anatomy, and zonal stent-graft placement was performed to seal the entry tear and promote thrombosis of the false lumen. Results A total of 18 patients (15 males, 3 females) were included, with a mean age of (53.5±10.6) years (range, 39 to 76 years). The median operation time was 38.0 (29.5, 58.5) min, and the median intraoperative blood loss was 20.0 (20.0, 30.0) mL. The technical success rate was 100.0%. Intraoperative and postoperative imaging confirmed successful exclusion of the distal entry tear of the IMH, with no endoleak, stenosis or occlusion of visceral branches. There were no major perioperative complications, such as death, paraplegia, or visceral ischemia. During follow-up, complete thrombosis or resolution of the false lumen was observed in all patients. Conclusion For patients with residual entry tears and new-onset dissection-like changes in the distal aorta after the first-stage procedure for IMH, second-stage stent-graft placement can effectively seal the entry tear, promote false lumen thrombosis and hematoma resolution, and improve distal aortic remodeling, demonstrating favorable short- to mid-term outcomes.

Citation： CHEN Bailang, WANG Zanxin, ZHUANG Xianmian, LIU Haibing, WEI Minxin. Secondary stent placement for sealing distal tears in aortic intramural hematoma and enhancing distal aortic remodeling: A retrospective study in a single center. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2026, 33(6): 944-951. doi: 10.7507/1007-4848.202406074 Copy

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2.	Sorber R, Hicks CW. Diagnosis and management of acute aortic syndromes: dissection, penetrating aortic ulcer, and intramural hematoma. Curr Cardiol Rep, 2022, 24(3): 209-216.
3.	Vacirca A, Dias Neto M, Baghbani-Oskouei A, et al. Timing of intervention for aortic intramural hematoma. Ann Vasc Surg, 2023, 94: 14-21.
4.	Boufi M, Patterson BO, Grima MJ, et al. Systematic review of reintervention after thoracic endovascular repair for chronic type B dissection. Ann Thorac Surg, 2017, 103(6): 1992-2004.
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6.	Jiang X, Pan T, Liu Y, et al. Prognostic implications of initial focal contrast enhancement in acute type B intramural hematoma. J Am Coll Cardiol, 2024, 83(4): 503-513.
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8.	Chin AS, Willemink MJ, Kino A, et al. Acute limited intimal tears of the thoracic aorta. J Am Coll Cardiol, 2018, 71(24): 2773-2785.
9.	Shao T, Bornak A, Kang N. Penetrating aortic ulcer and aortic intramural hematoma: treatment strategy. Vascular, 2023, 31(6): 1086-1093.
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11.	中華醫學會外科學分會血管外科學組. Stanford B型主動脈夾層診斷和治療中國專家共識(2022版). 中國血管外科雜志(電子版), 2022, 14(2): 119-130.Society of Vascular Surgery, Surgery Branch of Chinese Medical Association. Chinese expert consensus on the diagnosis and treatment of Stanford type B aortic dissection (2022 edition). Chin J Vasc Surg (Electron Ver), 2022, 14(2): 119-130.
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13.	Chen B, Zhang R, Liu H, et al. Efficacy of endovascular repair in the treatment of retrograde ascending aortic intramural haematoma. J Cardiothorac Surg, 2023, 18(1): 130.
14.	K?rkk?inen JM, Tenorio ER, Pather K, et al. Outcomes of small renal artery targets in patients treated by fenestrated-branched endovascular aortic repair. Eur J Vasc Endovasc Surg, 2020, 59(6): 910-917.
15.	孫巖, 王玉濤, 張十一, 等. 3D打印輔助開窗支架及分支支架技術治療累及內臟動脈區胸腹主動脈瘤的效果分析. 中國胸心血管外科臨床雜志, 2022, 29(1): 90-94.Sun Y, Wang YT, Zhang SY, et al. Effectiveness of endovascular repair with fenestration stent and branch stent assisted by 3D printing in treating thoracoabdominal aortic aneurysm involving visceral artery area. Chin J Clin Thorac Cardiovasc Surg, 2022, 29(1): 90-94.
16.	Gallitto E, Gargiulo M, Freyrie A, et al. Endovascular repair of thoracoabdominal aortic aneurysm in high-surgical risk patients: Fenestrated and branched endografts. Ann Vasc Surg, 2017, 40: 170-177.
17.	Ultee KHJ, Zettervall SL, Soden PA, et al. Perioperative outcome of endovascular repair for complex abdominal aortic aneurysms. J Vasc Surg, 2017, 65(6): 1567-1575.
18.	Wang R, Kan Y, Yang M, et al. Clinical results and aortic remodeling after endovascular treatment for complicated type B aortic dissection with the "fabulous" stent system. Front Cardiovasc Med, 2022, 9: 817675.
19.	?o?nierczuk M, Mi?kiewicz M, Paduch J, et al. Questionable long-term results of the extended provisional extension to induce complete attachment (E-PETTICOAT) technique in the management of chronic type B aortic dissection. Ann Vasc Surg, 2023, 89: 210-215.

1. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(41): 2873-2926.
2. Sorber R, Hicks CW. Diagnosis and management of acute aortic syndromes: dissection, penetrating aortic ulcer, and intramural hematoma. Curr Cardiol Rep, 2022, 24(3): 209-216.
3. Vacirca A, Dias Neto M, Baghbani-Oskouei A, et al. Timing of intervention for aortic intramural hematoma. Ann Vasc Surg, 2023, 94: 14-21.
4. Boufi M, Patterson BO, Grima MJ, et al. Systematic review of reintervention after thoracic endovascular repair for chronic type B dissection. Ann Thorac Surg, 2017, 103(6): 1992-2004.
5. Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines. Circulation, 2022, 146(24): e334-e482.
6. Jiang X, Pan T, Liu Y, et al. Prognostic implications of initial focal contrast enhancement in acute type B intramural hematoma. J Am Coll Cardiol, 2024, 83(4): 503-513.
7. Osada H, Kyogoku M, Ishidou M, et al. Aortic dissection in the outer third of the media: what is the role of the vasa vasorum in the triggering process? Eur J Cardiothorac Surg, 2013, 43(3): e82-e88.
8. Chin AS, Willemink MJ, Kino A, et al. Acute limited intimal tears of the thoracic aorta. J Am Coll Cardiol, 2018, 71(24): 2773-2785.
9. Shao T, Bornak A, Kang N. Penetrating aortic ulcer and aortic intramural hematoma: treatment strategy. Vascular, 2023, 31(6): 1086-1093.
10. Estrera AL, Sandhu HK, Leake SS, et al. Early and late outcomes of acute type A aortic dissection with intramural hematoma. J Thorac Cardiovasc Surg, 2015, 149(1): 137-142.
11. 中華醫學會外科學分會血管外科學組. Stanford B型主動脈夾層診斷和治療中國專家共識(2022版). 中國血管外科雜志(電子版), 2022, 14(2): 119-130.Society of Vascular Surgery, Surgery Branch of Chinese Medical Association. Chinese expert consensus on the diagnosis and treatment of Stanford type B aortic dissection (2022 edition). Chin J Vasc Surg (Electron Ver), 2022, 14(2): 119-130.
12. 徐樂吟, 來志超, 邵江, 等. Stanford B型主動脈夾層遠端破口的腔內治療策略. 中華外科雜志, 2021, 59(8): 711-715.Xu LY, Lai ZC, Shao J, et al. Endovascular treatment strategies for distal entry tear of Stanford type B aortic dissection. Chin J Surg, 2021, 59(8): 711-715.
13. Chen B, Zhang R, Liu H, et al. Efficacy of endovascular repair in the treatment of retrograde ascending aortic intramural haematoma. J Cardiothorac Surg, 2023, 18(1): 130.
14. K?rkk?inen JM, Tenorio ER, Pather K, et al. Outcomes of small renal artery targets in patients treated by fenestrated-branched endovascular aortic repair. Eur J Vasc Endovasc Surg, 2020, 59(6): 910-917.
15. 孫巖, 王玉濤, 張十一, 等. 3D打印輔助開窗支架及分支支架技術治療累及內臟動脈區胸腹主動脈瘤的效果分析. 中國胸心血管外科臨床雜志, 2022, 29(1): 90-94.Sun Y, Wang YT, Zhang SY, et al. Effectiveness of endovascular repair with fenestration stent and branch stent assisted by 3D printing in treating thoracoabdominal aortic aneurysm involving visceral artery area. Chin J Clin Thorac Cardiovasc Surg, 2022, 29(1): 90-94.
16. Gallitto E, Gargiulo M, Freyrie A, et al. Endovascular repair of thoracoabdominal aortic aneurysm in high-surgical risk patients: Fenestrated and branched endografts. Ann Vasc Surg, 2017, 40: 170-177.
17. Ultee KHJ, Zettervall SL, Soden PA, et al. Perioperative outcome of endovascular repair for complex abdominal aortic aneurysms. J Vasc Surg, 2017, 65(6): 1567-1575.
18. Wang R, Kan Y, Yang M, et al. Clinical results and aortic remodeling after endovascular treatment for complicated type B aortic dissection with the "fabulous" stent system. Front Cardiovasc Med, 2022, 9: 817675.
19. ?o?nierczuk M, Mi?kiewicz M, Paduch J, et al. Questionable long-term results of the extended provisional extension to induce complete attachment (E-PETTICOAT) technique in the management of chronic type B aortic dissection. Ann Vasc Surg, 2023, 89: 210-215.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Secondary stent placement for sealing distal tears in aortic intramural hematoma and enhancing distal aortic remodeling: A retrospective study in a single center

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