| Cohort follow-up study and prognostic analysis of type A intramural hematomaObjectives:To explore the prognostic difference of patients with type A intramural hematoma(IMH)by different treatment methods and the risk factors of death of patients with conservative treatment.Methods:This retrospectively study enrolled patients diagnosed with type A IMH in the first CT examination at fuwai hospital of Chinese Academy of Medical Sciences between September 2009 and June 2018,Including 154 cases by surgical treatment and 130 cases of conservative treatment.Baseline clinical and CT characteristics were recorded.All patients enrolled were followed up.The endpoint was aortic disease-related death.Patients with conservative treatment were divided into endpoint group and non-endpoint group according to whether or not an endpoint event occurs.Difference between two groups of normally distributed continuous variables,non-normally distributed continuous variables and categorical variables were tested by independent sample t test,Mann-Whitney U test and chi-square test or Fisher's exact test,respectively.Independent risk factors related to outcomes were assessed with Cox regression analysis and survival analysis.Results:Compared with conservative treatment group,patients in surgical treatment group had higher C-reactive protein(CRP)(60.4mg/L vs.17.5mg/L,P=0.019),greater maximum hematoma thickness(MTH)(12.6mm vs.11.0mm,P<0.001),and higher proportion of patients with hyperlipidemia,ulcerlike projection(ULP)and pericardial effusion(53.9%vs.23.8%,P<0.001,73.4%vs.43.1%,P<0.001,58.4%vs.39.2%,P=0.001),but the median age of patients is younger(59.5 years vs.63,0 years,P=0.005),the proportion of patients with aortic atherosclerosis is less(55.2%vs.70.0%,P=0.010).During a median follow-up time of 1000(452,1623)days,there were 8 cases and 26 eases of aortic disease-related death in surgical treatment group and conservative treatment group,respectively.The Kaplan-Meier survival curve showed that the prognosis of the conservative treatment was poor(P<0.001).Compared with non-endpoint group patients,patients with conservative treatment who experienced aortic disease-related death showed older age and larger MAD[(66.5±9.6)years vs.(61.0±10.9)years,P=0.020,(53.5±7.2)mm vs.(48.2±6.6)mm,P<0.001],higher proportion of aortic atherosclerosis,ULP and pericardial effusion(88.5%vs.65.4%,P=0.022,65.4%vs.37.5%,P=0.010,65.4%vs.32.7%,P=0.002).In Cox regression multivariate analysis shows that aortic atherosclerosis(HR=3.48,P=0.043),ULP(HR=2.66,P=0.019)and pericardial effusion(HR=2.49,P=0.030)were independent risk factors for death in patients with conservative treatment.Conclusions:The prognosis of surgical treatment for type A IMH patients is significantly better than conservative treatment,but the best treatment should be selected in accordance with the actual situation.Aortic atherosclerosis,ULP and pericardial effusion are in dependent predictors of subsequent aortic disease-related death for type A IMH patients with conservative therapy,identifying these risk factors is helpful for further risk stratification and decisions-making.CT imaging characteristics of progression and analysis of predictive model for adverse events in type A intramural hematomaObjectives:By reviewing the initial and follow-up CT performance,our aim is to explore the factors affecting progression of type A IMH and the prognostic value of follow-up CT for patients who initially receive conservative treatment.Methods:97 consecutive patients with baseline and at least one followup CT of type A IMH from September 2009 to June 2018 were enrolled in this study.Baseline clinical and CT characteristics were recorded.The endpoint of follow-up was defined as adverse aorta-related events,including non-emergency aortic surgery or interventional treatment,progression to aneurysm,dissection or aortic rupture,and aortic death.First,we explored the relationship between the changes of IMH indicators and baseline CT characteristics,and illustrated the trend of indicator changes with the time of onset.A simple predictive model and a combined predictive model of adverse aorta-related events were established by baseline CT data and baseline CT plus follow-up CT data,respectively,and the ROC curve was used to compare the diagnostic efficiency of the predictive model.Cox regression analysis was performed on the follow-up results.Results:The median follow-up time was 409(27-1575)days.During the follow-up period,50 patients(51.5%)had an endpoint event.Patients with a baseline maximum hematoma thickness(MTH)>11mm had a significantly greater proportion of intramural blood pool(IBP)progression(42.9%vs.12.5%,P=0.001).The maximum aortic diameter(MAD)and MTH gradually change from increasing to decreasing with the onset of time(all P<0.001),and the proportion of patients with increased pericardial effusion and pleural effusion gradually decreases with the onset of time(P=0.028,0.047),the proportion of patients with intimal rupture and IBP progression did not change significantly in different periods(P=1.000,0.856).The simple predictive model includes MAD?50mm(OR=2.58,P=0.043)and intimal rupture(OR=2.69,P=0.028)in baseline CT,the combined predictive model includes intimal rupture in baseline CT(OR=3.85,P=0.012),increased MTH in follow-up CT(OR=1.23,P=0.001)and increased pericardial effusion(OR=4.25,P=0.059).The diagnostic efficiency of the combined predictive model with area under receiver operating characteristic curve(AUC)of 0.82 was better than that of the simple predictive model(AUC=0.66).In addition,patients with intimal rupture(HR=2.13,P=0.024),increased MTH(HR=1.12,P=0.001)and increased pericardial effusion(HR=1.98,P=0.051)had lower event-free survival rates.Conclusions:Both intimal rupture and IBP in patients with type A IMH will progress at different periods,but the prognosis of intimal rupture is poor,and other indicators gradually improve with the onset of time.For patients with type A IMH who initially received medical management,initial and follow-up CT is valuable for predicting adverse aorta-related events,regular follow-up examination could provide more help for clinical treatment decisions.The study for correlation and CT imaging characteristics of ulcer-like projection in type A intramural hematomaObjectives:We explored the relationship between ulcer-like projection and type A intramural hematoma(IMH)to determine the trend of disease progression and realize the occurrence and development of IMH.Methods:148 patients who diagnosed as type A IMH with ulcer-like projection from September 2009 to June 2018 were enrolled in this study.Baseline clinical and CT characteristics were recorded.The endpoint of follow-up was defined as adverse aorta-related events,including nonemergency aortic surgery or interventional treatment,progression to aneurysm,dissection or aortic rupture,and aortic death.We Described in detail the number,location,width and depth of ULPs,and analyzed the relationship between each index and the maximum aortic diameter(MAD),maximum hematoma thickness(MTH),pericardial effusion,pleural effusion and hematoma morphology.Spearman rank correlation analysis was used to evaluate the correlation between ULP index and MAD and MTH,nonparametric Mann-Whitney U test was used to evaluate the difference between each ULP index in the group with and without pericardial effusion,the group with and without pleural effusion,and the group with different hematoma morphology.The ROC curve was used to determine the optimal cutoff values for width and depth of ULPs for predicting adverse aorta-related events,and Cox regression analysis was performed for ULP indicators.Results:A total of 178 ULPs were detected in all patients,102 located in ascending aorta(57.3%),48 located in aortic arch(27.0%),20 located in thoracic descending aorta(11.2%),8 located in abdominal aorta(4.5%),the median width of ULPs was 9.6(6.7,14.3)mm,and the median depth of ULPs was 6.6(4.5,9.5)mm.MAD and MTH increase as the number of ULPs increases,the closer ULP is to the proximal end of aorta,and the width and depth of ULPs increase,but only the correlation between the depth of ULPs and MAD and MTH are significantly different(r=0.359,P<0.001,r=0.343,P<0.001).Compared with the non-pericardial effusion group,the location of ULPs was closer to the proximal end of aorta in the pericardial effusion group(4 vs.3,P<0.001),and the width and depth of ULPs were larger(10.8mm vs.8.4mm,P<0.001,7.4mm vs.5.7mm,P=0.015),but the number of ULPs was no difference in both groups(1 vs.1,P=0.303).The above four indicators were not statistically significant in the group with or without pleural effusion and the group with different hematoma morphology.The optimal cutoff values for the width and depth of ULPs to predict adverse aorta-related events were 13.55mm and 8.55mm,respectively.Only ULPs located in ascending aorta are independent predictors of adverse aorta-related events(HR=1.59,P=0.019).Conclusions:ULP is formed on the basis of intimal rupture and related to the occurrence and development of IMH.Its indicators,especially the depth of ULPs,are closely related to traditional risk factors in CT imaging.The occurrence of ULP in ascending aorta of type A IMH is required to focus and close follow-up,and timely surgery if necessary. |
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