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Focal Contrast Enhancement in Acute Type B Intramural Hematoma
Quick Takes
- In a retrospective study of patients with acute type B intramural hematoma, pleural effusion and focal contrast enhancement on initial CT angiography were independent risk factors for adverse aortic events (AAEs).
- In subgroup analysis, patients with focal intimal disruption (FID) were more likely to progress than were patients with intramural blood pool (IBP); and FID location in the proximal descending aorta was associated with AAEs, whereas no significant predictors of AAEs were identified in patients with IBP.
Study Questions:
What are the prognostic implications of focal contrast enhancement (FCE) on computed tomographic angiography (CTA) in acute type B intramural hematoma (IMH)?
Methods:
In a retrospective study, data were reviewed from patients who underwent CTA at two centers in China from 2009–2019. Patients with acute aortic syndrome and evidence of FCE accompanying type B IMH on the initial CTA were included in the analysis; because they underwent emergent surgery, patients with maximal FCE dimension >20 mm were excluded. FCE included focal intimal disruption (FID; defined as intimal disruption with contrast-filled out-pouching from the aortic lumen with a communicating orifice >3 mm) and intramural blood pool (IBP; defined as a localized contrast medium-filled pool inside the IMH). Adverse aortic events (AAEs) were defined as aorta-related death or the need for surgical/endovascular intervention due to disease progression.
Results:
A total of 574 patients were enrolled. Of these, 207 (36.1 %) had FCE on the initial CTA, including 132 (63.8% of FCEs) with FID and 75 (36.2% of FCEs) with IBP. Patients with FCE were more likely to have hypertension (p = 0.001), pleural effusion (p = 0.006), fewer aortic segments involved (p < 0.001), more AAEs (41.5% vs. 26.4%, p < 0.001), and lower freedom from intervention (p = 0.002). Pleural effusion (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.25-2.55; p = 0.001) and FCE (HR, 1.51; 95% CI, 1.12-2.02; p = 0.006) were independent risk factors for AAEs. In subgroup analysis, patients with IMH and FID were more likely to progress than were those with IBP (p < 0.001), and FID location in the proximal descending aorta was associated with AAEs (HR, 2.95; 95% CI, 1.65-5.29; p < 0.001). No significant predictors of AAEs were identified in patients with IBP.
Conclusions:
Patients with FCE accompanying type B IMH were more likely to progress, especially in those with FID located in the proximal descending aorta.
Perspective:
Previous literature has suggested that new FID in the setting of type B IMH is associated with an increased risk of aortic rupture, whereas IBP might not be associated with adverse outcomes. In this study, the incidence of AAEs associated with type B IMH was higher among patients with FCE on initial imaging (41.5%) compared to those without (26.4%), and disease progression was more likely among patients with FID than among those with IBP. Because FID and IBP might represent different pathologies with different clinical courses, the findings of this study could be helpful in determining follow-up among patients with type B IMH without and with FCE on initial imaging.
Clinical Topics: Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Computed Tomography, Nuclear Imaging, Vascular Medicine
Keywords: Hematoma, Computed Tomography Angiography
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