The Follow-up Study Of Aortic Intramural Hematoma

Part1The follow-up of type B aortic intramural hematoma with conservative treatmentObjective:The current treatment strategy for Stanford type B aortic intramural hematoma is still controversial. This study was by observing and analyzing the periodic follow-up images of type B intramural hematoma to explore its outcome characteristics, so as to provide evidence to support the treatment strategies.Material and Methods:From January2009to January2012, there were seventy-three patients of type B intramural hematoma only treated by conservative medicine, among them there were56male patients,17females, aged38to81years, and the average age was56.12±9.38years. All patients were examined by regular CTA follow-up. In this group, each patient underwent CTA for more than three times. In order to better explore the absorption rule of intramural hematoma, the levels of absorption of hematoma were divided into five grades(Ⅰ-Ⅴ grade) by the changes of the intramural hematoma thickness. In order to approach the relationship between the contrast medium flush in intramural hematoma (crescent or ring with medium density) zone and intramural hematoma progress, it was divided into type Ⅰ (Ⅰa, Ⅰ b, Ⅰ c) and Ⅱ (Ⅱ a and Ⅱ b) by the image features.Results:During the follow-up of seventy-three type B intramural hematoma patents, there were two cases of true aneurysm, six cases of local dissection. The situation of sixty-seven cases of absorption of intramural hematoma (seventy-three cases except for the six cases of local dissection) was:the CTA follow-up result (one week) was there were62cases (92.5%) of grade Ⅴ (no change) intramural hematoma absorption, four cases (6.0%) of grade Ⅳ (improved absorption), no grade Ⅲ (obvious absorption), one case (1.5%) of grade Ⅱ (fundamental absorption), no grade Ⅰ (complete absorption); the CTA follow-up result (1month) was there were2cases (3.0%) of V grade intramural hematoma absorption, no grade Ⅳ,15cases (22.4%) of grade Ⅲ,19cases (28.3%) of grade Ⅱ,31cases (46.3%) of grade I; the CTA follow-up result (three months) was there were no v grade of intramural hematoma absorption,2cases (3.0%) of grade Ⅲ,9cases (13.4%) of grade Ⅱ and56cases (83.6%) of grade Ⅰ. With time going on, the symptom of two cases of a small amount of pericardial effusion,32cases of a small amount of bilateral pleural effusion, five cases of a small amount of left pleural effusion,11cases of partial incomplete lung tissue expansion and one case of new bilateral pleural effusion as well as partial incomplete lung tissue expansion all disappeared in5weeks. We could observe the contrast medium flush appeared in the new type Ⅰ (11cases) and new type Ⅱ (three cases) in one month follow-up. We could get19cases of type Ⅰcontrast medium flush from regarding the new formed and newly diagnosed type Ⅰ and type Ⅱ contrast medium flush as the initial contrast medium flush, among them there were36type Ⅰ a contrast medium flush,10type Ⅰ b contrast medium flush,6type Ⅰ c contrast medium flush; we also could get35cases of type Ⅱ contrast medium flush shadow. The changes of the contrast medium flush in the follow-up was36type Ⅰ a, among them there were11absorption and disappearing,12changing small,9non-significant change,4changing big;10type Ⅰ b, among them, there were9absorption and disappearing,1non-significant change;6type Ⅰ c, among them, there were2absorption and disappearing,1changing small,3non-significant change; among35cases of type Ⅱ a contrast medium flush, there were2cases (5.7%) absorption and disappearing (single small contrast medium flush of aortic arch);5cases (14.3%) of changing small;17cases (48.6%) of no obvious changes;11cases (31.4%) progress big.Conclusion:The absorption trend of type B intramural hematoma would not affect by the absorption, progressing or emerging of the complications. Pericardial effusion and pleural effusion usually was absorbed and disappeared in five weeks, and it had no clear correlation of whether the intramural hematoma was progressing to the aortic dissection. The changes of various types of contrast medium flush was in diversity, including absorbed and disappeared, absorbed and to be smaller, no significant changes, progressed largely and emerging; Type Ⅰa contrast medium flush (especially emerging) and type II a contrast medium flush (ulcers) located in the proximal abdominal aorta had risk of causing local dissection; More scattered type II a contrast medium flush located in the aortic arch (ulcers) was the main reason of true aneurysm; The risk of type Ⅰ b and Type Ⅰ c was low. The formation of local dissection could be absorbed better or stable, and the risk of adverse progress was low. Part2The follow-up of type B aortic intramural hematoma with two kinds of treatments:endovascular stent-graft and conservative treatment Objective:Discuss the best treatment strategy for type B aortic intramural hematoma by comparing the follow-up results of endovascular stent-graft treatment (ESGT) and conservative medicine treatment for Stanford type B aortic intramural hematoma.Methods:From January2009to January2012,92patients were treated in hospital due to sudden chest-back pain or abdominal pain, and it was diagnosed as Stanford B type aortic intramural hematoma by CT examination. To compare the two treatments,19cases of endovascular stent-graft treatment were classified as the intervention group; except for type B aortic intramural hematoma with no intimal lesion in the aortic arch,32cases of conservative medicine treatment (there was contrast medium flush in the aortic arch, including2cases of type Ⅰ a,30cases of Ⅱ a, that is ulcer) in the73cases aortic arch were classified as medicine group. Among them, there were38males and13females, aged37to81years, average age were57.1±10.7years.Results:There were16cases and25cases of grade I absorption of intramural hematoma in the intervention group and in the medicine group respectively during the follow-up. In the intervention group, the arch contrast medium flush disappeared completely in19cases. In the medicine group, it disappeared only in4cases and progressed in9cases. There were no newly emerging type I contrast medium flush in the intervention group but3cases in medicine group. The complications (pericardial effusion, pleural effusion, part of atelectasis) in the two groups were all absorbed and disappeared. There was lcase of abdominal aorta distal local dissection in the intervention group, but it was absorbed and disappeared in the follow-up observation. There were2cases of local dissection,1case in the thoracoabdominal aorta,1case in the abdominal aorta proximal to the double-renal arteries in the medicine group, and there was no significant change in the follow-up; there were also2cases of true aneurysm of aortic arch, and there was no significant change in the follow-up.Conclusion:The results of this study showed that both the ESGT and conservative medicine treatment for B-type of IMH had achieved good results in the absorption of hematoma and complications (pericardial effusion, pleural effusion, part of the atelectasis); ESGT had a significant advantage over aortic arch ulcers (Ⅱ a contrast medium flush); as for the follow-up disease of abdominal aortic (local dissection) ESGT had advantage over conservative medicine treatment. Part3The follow-up of Stanford type A aortic intramural hematoma with conservative treatmentObjective:This study discussed the value of treating type A aortic intramural hematoma with medicine treatment by observing and analyzing the follow-up image of Stanford A aortic intramural hematoma treating only with medicine.Methods:From January2009to January2012,58patients in my hospital diagnosed as type A aortic intramural hematoma by CT examination, among them, there were18patients with combination type B aortic dissection,17patients undergoing surgical treatment, the remaining23patients received only conservative medicine treatment. This study discussed the effect of medicine treatment by analyzing of the latter23patients' follow-up image, among them, there were18male,5female, who were aged42to74years, and with the average age of56.6±8.9years old.Results:During follow-up, there were no death in the group of23patients, and no major complications (local dissection, aneurysm, aortic rupture, etc.) occurred. In the23patients of type A aortic intramural hematoma, there were23/23(100%) of grade I absorption (complete absorption)located in the ascending aorta intramural hematoma,19/23(82.6%) of grade Ⅰ absorption located in the descending aorta and/or abdominal aorta intramural hematoma,4/23(17.4%) of absorption Ⅱ (fundamental absorption). Among the23patients, there were4patients with contrast medium flush (scattered in the descending aorta) absorbed and disappeared;1patient with type Ⅰ contrast medium flush (scattered in the descending aorta and abdominal aorta) absorbed and improved;2patients with type Ⅰ contrast medium flush (scattered in the abdominal aorta) of no significant change;5patients with type Ⅱ a contrast medium flush (ulcer) in aortic arch,1in which was advanced largely,4in which was with no significant changes; the pericardial effusion in16cases and the partial lung atelectasis in14cases were all but disappeared, and the pleural effusion in20cases (including19patients of newly diagnosed and1follow-up patient) were absorbed and disappeared.Conclusions:Conservative medicine treatment for the type A aortic intramural hematoma could get good results, when the ascending aortic intramural hematoma without contrast medium flush, but need for regular image follow-up.