Hybrid Repair of Ascending Aortic Intramural Hematoma and Arch Ulcer in a 74-Year-Old Woman – A Case Report

Introduction

Intramural hematoma (IMH) with a penetrating atherosclerotic ulcer (PAU) involving the ascending aorta and aortic arch is a unique condition among acute aortic syndromes [1]. Type A IMH affects the ascending aorta and may extend to the aortic arch, presenting a considerable challenge in cardiovascular medicine due to its complex pathology and the high risk of aortic rupture, leading to increased mortality [2]. The incidence of IMH in type A acute aortic syndrome cases ranges from 15% to 44.3% [3–5]. The management of IMH depends on its location, the extent of hematoma thickness, and the presence of critical sequelae, such as pericardial effusion, rupture, severe aortic regurgitation, or organ malperfusion. Current guidelines, including the 2010 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) and 2014 European Society of Cardiology recommendations [6,7], advocate for urgent surgical repair in cases of “complicated” type A IMH presenting with these critical complications. However, surgical indications for “uncomplicated” type A IMH are less clearly established. Standard open aortic arch repair requires cardiopulmonary bypass, deep hypothermic circulatory arrest, and arch replacement, procedures that carry high mortality and morbidity, especially in high-risk patients with additional health conditions [8].

Dacron aortic wrapping serves as a less-invasive surgical alternative, reinforcing the ascending aorta externally with a Dacron graft. This approach provides mechanical support without extensive dissection, making it suitable for high-risk patients who may not tolerate conventional open surgery [9]. Transcatheter endovascular aortic repair (TEVAR) has also become valuable for managing aortic arch and descending aortic diseases [10], paving the way for less-invasive procedures and improved perioperative outcomes. The hybrid arch concept combines supra-aortic debranching with endovascular repair as an alternative to conventional open repair, especially for high-risk patients. This approach repositions the supraaortic branches to create a landing zone for stent grafts, enabling less-invasive aortic arch repair. As Ishimaru describes, hybrid procedures with supra-aortic debranching show promise in complex aortic arch disease by reducing the need for cardiopulmonary bypass and deep hypothermic circulatory arrest [11]. While endovascular stent grafting is widely used for descending aortic diseases, its application in aortic diseases involving the ascending aorta and aortic arch can be technically complex due to the engagement of the supra-aortic branches. Furthermore, its effectiveness could be constrained by the lack of suitable landing zones and the potential risk of endoleaks [12]. While hybrid repair strategies for aortic arch pathology have been previously described, including the techniques of external wrapping and in-situ fenestration, our approach integrates these methods into a single comprehensive hybrid procedure. This combined approach leverages the stability offered by the wrapping technique and the precision of in-situ fenestration, aiming to minimize surgical risks while achieving effective repair in a high-risk patient. To overcome these challenges, the concept of endovascular hybrid repair has emerged as a strategy to fuse the benefits of surgical and endovascular approaches. By merging off-pump ascending aortic external wrapping with supra-aortic debranching and endovascular repair [13], this technique aims to address the complex anatomical considerations of aortic diseases involving the ascending aorta and aortic arch, while reducing the need for cardiopulmonary bypass and aortic cross-clamping [14].

In this case report, we introduce a novel hybrid procedure combining off-pump external wrapping of the ascending aorta with endovascular stent grafting of the aortic arch, using an in-situ fenestration technique. Through this report, we aim to bolster the expanding knowledge base of endovascular hybrid repair for intricate aortic pathologies, especially in high-risk patients with type A IMH with PAU involving the ascending aorta and aortic arch. By sharing our experience and examining existing literature, we strive to offer insights into the procedural considerations, patient outcomes, and potential future developments for this emerging treatment approach.

This report describes a 74-year-old hypertensive woman with type A IMH, managed with hybrid surgery including external Dacron wrapping of the ascending aorta and endovascular stenting of the aortic arch with fenestration of the origins of the supra-aortic arteries. Given the high-risk profile of the patient for conventional cardiopulmonary bypass surgery, this minimally invasive approach presents an alternative that may be safer and still effective. Through this case, we aim to contribute insights into procedural considerations, patient outcomes, and the potential role of hybrid techniques in managing complex aortic disease in high-risk patients.

Case Report

PATIENT INFORMATION:

A 74-year-old woman was referred to our center after investigations for chest pain diagnosed as type A IMH. The patient had a history of hypertension, diabetes mellitus, chronic kidney disease, and coronary artery disease. She had undergone percutaneous coronary intervention 2 years ago. On the day of admission, a computed tomography angiography (CTA) examination confirmed the presence of a dilated ascending aorta (48.9 mm) and a type A IMH involving the ascending aorta and the aortic arch, with the hematoma extending to near the origin of the left carotid artery. The thickest part of the hematoma in the ascending aorta was approximately

1.57 cm (Figure 1A–1C). The patient was treated medically with intensive antihypertensive therapy in the intensive care unit for 1 day. After stabilizing the blood pressure, the patient was subsequently transferred to a regular ward where she rested in bed for 10 days, maintaining systolic blood pressure between 100 and 130 mmHg. One week after admission, a follow-up CTA was performed, showing that the degree of the type A intramural hematoma was similar to the initial examination. However, this time, the CTA follow-up showed a more prominent isolated PAU near the ascending aortic arch (top of the red arrow, 10×10 mm) than before (Figure 1D). Given the patient’s high surgical risk, we initially opted for conservative management with intensive antihypertensive therapy, monitoring the IMH over a 1-week period. This approach aimed to observe for potential partial absorption of the hematoma, which could help stabilize the condition and reduce surgical risks associated with subsequent intervention. However, after 1 week, imaging indicated no change in the IMH’s size or configuration, and a more prominent PAU was noted in the aortic arch. These findings led to our decision to proceed with a hybrid intervention, addressing the IMH and PAU while minimizing invasiveness.

The patient was deemed to be high risk for conventional open surgery due to her advanced age and comorbidities. Given the patient’s advanced age and multiple comorbidities – including hypertension, insulin-dependent diabetes mellitus, chronic kidney disease, extracardiac arteriopathy, moderate left ventricular ejection fraction (LVEF; 45%), and New York Heart Association class III functional status – the patient was assessed to be at high surgical risk. This assessment was supported by a EuroSCORE II value of 11.66%. Consequently, a conventional open surgical approach was deemed unsuitable, and a hybrid intervention strategy was chosen to minimize procedural risks while addressing her condition effectively. However, a single endovascular stent intervention was not feasible due to the lack of a suitable anchoring area in the ascending aorta for prosthesis placement. Therefore, after obtaining informed consent, we decided to perform a hybrid repair with off-pump external wrapping of the ascending aorta combined with TEVAR of the aortic arch, which included in-situ fenestration stenting to maintain supra-aortic branch patency. To overcome this obstacle, we wrapped the ascending aorta with a Dacron tube, thereby reducing the diameter of the distal ascending aorta to form an anchoring zone where a vascular stent could be placed.

TECHNICAL PROCEDURE:

The procedure was performed in a hybrid operating room under general anesthesia. The patient was placed in a supine position with the left arm abducted. The procedure was performed under normothermic conditions, as the patient’s hemodynamic stability and the expected shorter duration of the intervention were deemed sufficient to mitigate ischemic risk without the need for hypothermia. A median sternotomy was performed and the ascending aorta was carefully separated from the pulmonary artery trunk and the right pulmonary artery. A piece of about 13 cm long and 6 cm wide was cut and trimmed from a polyester artificial blood vessel graft (Terumo Corporation, Tokyo, Japan). It was wrapped gradually around the ascending aorta from approximately 2.5 cm above the sinotubular junction to the brachiocephalic artery origin, and secured with 4-0 Prolene (Ethicon, Somerville, NJ) sutures. This formed a wrapped artificial blood vessel ring of about 6 cm long and 12.5 cm in circumference (Figure 2A). A radiopaque metal wire (Figure 2B, top of the red arrow) from the contrast gauze was tied around the proximal end of the ring for stent implantation positioning.

Then, a 4-cm incision was made in the right inguinal area to expose the right femoral artery. A 5-cm incision was made in the neck along the left sternocleidomastoid muscle area to expose the left common carotid artery. The same method was used to expose the right common carotid artery. Finally, a 2-cm incision was made at the left elbow to expose the left brachial artery. Heparin (1 mg/kg) was used for intravenous injection of systemic heparinization. A pigtail catheter was inserted into the ascending aorta through the left femoral artery for angiography.

The interventional stent implantation is shown in Figure 2C–2J. A thoracic stent graft with the specification XJZDZ30160 (Ankura, Lifetech Scientific Company, Ltd., Shenzhen, China) was delivered through the right femoral artery and deployed at the predetermined position in the descending aorta. The proximal end of a second thoracic stent graft with the specification XJZDZ42200 (Ankura, Lifetech Scientific Company, Ltd., Shenzhen, China) was guided to the middle of the wrapped ascending aorta and overlapped with the polyester graft to safely position the landing zone of the proximal ascending aorta. The distal end was then overlapped and constrained in the middle position of the first thoracic stent graft, ensuring complete coverage of the PAU. Before the second thoracic stent graft occluded the aortic arch branches, a dilator of a 14F Check-Flo introducer sheath (Cook Medical, Bloomington, IN, USA) was inserted into the ascending aorta via a guidewire through the right common carotid artery puncture point, creating a gap between the brachiocephalic artery and the ascending aorta to preserve cerebral blood flow.

Immediately after the second thoracic stent graft deployment, the puncture system was inserted via the left common carotid artery, and a balloon-expansible Express LD 10×37 mm stent (Boston Scientific Corporation, Natick, MA, USA) was penetrated in a retrograde manner for fenestration; a 0.035-inch wire (180-cmAmplatz super stiff guidewire; Boston Scientific; Natick, MA, USA) was then passed into the ascending aorta to enable pre-dilatation with the use of 4- mm and 8-mm balloons (MUSTANG; Boston Scientific, Marlborough, MA, USA). The puncture system consisted of an 18-gauge/30-cm needle (percutaneous transhepatic cholangiography needle; Hakko Co, Ltd, Tokyo, Japan) with a mildly bent tip. The fenestration via the brachiocephalic artery was also performed in a similar manner using a 5-mm (MUSTANG; Boston Scientific, Marlborough, MA, USA) dilatation catheter and a 12-mm SABER™ PTA dilatation catheter (Cordis, Santa Clara, CA, USA), followed by the implantation of an iliac artery stent with the specification IE-1416-080 (Yuranos, Lifetech Scientific Company, Ltd., Shenzhen, China). The left subclavian artery was punctured with the use of an adjustable puncture system containing a 9F Fustar Steerable sheath (Lifetech, Shenzhen, China), and a 0.035-inch wire (Cook Medical, Bloomington, IN, USA) was passed into the ascending aorta to perform the fenestration using 4-mm and 8-mm balloons (MUSTANG; Boston Scientific, Marlborough, MA, USA).

Post-deployment angiography confirmed that the large vascular stent and the brachiocephalic artery, the left common carotid artery, and the left subclavian artery had smooth blood flow, the penetrating ulcer was completely covered, and no endoleak was seen outside the large stent. The femoral, carotid, and brachial artery incisions were sutured and checked for hemostasis. A drainage tube was placed in the pericardial cavity and behind the sternum. The sternum was then secured with wire, and the skin incisions were closed in layers.

OUTCOME:

The patient was transferred to the intensive care unit and extubated on the same day. She had an uneventful postoperative course and was discharged on the seventh postoperative day. After surgery, approximately 60 mL of fluid was drained from the pericardial cavity drainage tube on the first postoperative day, following which the drainage tube was removed. The patient’s recovery was characterized by gradual improvement in her clinical status, without any neurological or visceral ischemic events. Postoperative CTA demonstrated preserved patency of the supra-aortic branches and no evidence of endoleak or graft-related complications.

At the 5-month follow-up, the patient remained asymptomatic, with no recurrence of chest pain or other cardiovascular symptoms. A follow-up CTA was performed, revealing that the stent graft was well-positioned with no signs of migration or endoleak (Figure 3A, 3B). The previously noted PAU was completely excluded, and the diameter of the ascending aorta remained stable with no further dilation. The supra-aortic branches continued to demonstrate preserved patency, and there were no signs of stent graft-related complications. The patient continued to show stable recovery with no adverse events.

Discussion

This case report demonstrates the feasibility and advantages of a novel hybrid approach for treating type A IMH with PAU, integrating external wrapping with TEVAR to achieve effective, minimally invasive aortic repair. This approach may serve as a viable alternative for patients who are unsuitable for open surgical repair, providing benefits in stability, reduced endoleak risk, and preserved aortic branch flow. Type A IMH with PAU is a life-threatening condition necessitating urgent intervention, but optimal management strategies remain controversial due to the lack of consensus on indications, timing, and intervention methods [15]. While open surgical repair has traditionally been the primary treatment, advances in endovascular techniques now offer less-invasive options. However, endovascular repair of type A IMH with PAU poses technical challenges, including the need for suitable landing zones, involvement of the ascending aorta and aortic arch, and risks of endoleaks or stent collapse [16].

In our hybrid procedure, combining off-pump external wrapping of the ascending aorta with in-situ fenestrated endovascular stent grafting of the aortic arch, we achieved both secure stent positioning and efficient revascularization of the supra-aortic branches. This technique also reduces procedural invasiveness and time, making it especially advantageous for high-risk patients. Moving forward, larger studies could further validate this approach’s broader application across diverse patient anatomies and clinical profiles, assessing its long-term feasibility and effectiveness.

The external wrapping technique has been previously reported for the treatment of various aortic pathologies, such as acute type A aortic dissection and ascending aortic aneurysm [17,18]. The results of these reports have shown favorable outcomes, with no mortality or major complications, and satisfactory long-term follow-up. However, the application of this external wrapping technique in combination with an in-situ fenestration technique in type A IMH has not been reported in case reports. Cases such as those documented by Antona et al [19] provide a foundational understanding of hybrid techniques for total arch repair, particularly through aortic neck reshaping within the aortic arch to establish a stable proximal landing zone. Their approach used external wrapping to create a non-expandable, cylindrical shape, which facilitated secure stent graft fixation within the aortic arch. In contrast, our procedure applies this concept to the ascending aorta, integrating advanced fenestration techniques to preserve flow to the supra-aortic branches. For patients like ours, who have type A intramural hematoma involving the ascending aorta, and the diameter of the ascending aorta is larger than 40 mm, the off-pump external wrapping technique is a simple and effective method to reinforce and reduce the circumference of the ascending aorta, which enables the arch stent to have an effective and sufficient anchoring zone in the ascending aorta [20]. The combination of off-pump external wrapping and endovascular stent grafting with an in-situ fenestration technique is a novel hybrid procedure that offers several advantages over the conventional open or endovascular approaches. First, it provides a stable and suitable landing zone for the stent graft in the ascending aorta, by reducing the diameter and reinforcing the wall of the dilated and weakened aorta. Second, it excludes the false lumen or penetrating ulcer, and restores the blood flow in the true lumen, by deploying a stent graft in the aortic arch. Third, it preserves the blood flow to the supra-aortic branches, by creating fenestrations in the stent graft using a retrograde puncture system. Fourth, it avoids the use of cardiopulmonary bypass and aortic cross-clamping, by performing the procedure off-pump and without the replacement of the native aorta. Fifth, it reduces operative time and blood loss, and improves perioperative outcomes, by utilizing minimally invasive techniques and avoiding major surgical incisions.

Our case report demonstrates the feasibility and safety of this hybrid procedure, as well as its short-term favorability. The patient had an uneventful postoperative course and was discharged on the seventh postoperative day. The postoperative CTA showed successful exclusion of the penetrating ulcer, patent supra-aortic branches, and no endoleak or graft-related complications. The patient’s recovery was characterized by gradual improvement in her clinical status, without any neurological or visceral ischemic events.

However, our case report has some limitations. First, it is a single case report, and the results may not be generalizable to other patients with different clinical characteristics and anatomical variations. Second, it is a retrospective study, and the data collection and analysis may be subject to bias and confounding factors. Third, it had a relatively short follow-up period, and the long-term durability and efficacy of this hybrid procedure are not yet established. Additionally, postoperative brain magnetic resonance imaging (MRI) was not performed in this case due to the patient’s stable neurological status, and standardized assessments of quality of life and functional capacity were not employed. Including these evaluations in future studies could help provide a more comprehensive understanding of the neurological and functional outcomes associated with this hybrid procedure. Therefore, further studies are needed to evaluate the performance and outcomes of this hybrid procedure, as well as to compare it with other treatment modalities, such as open surgery, endovascular repair, or medical therapy.

Conclusions

In conclusion, this case report introduces a novel hybrid procedure combining off-pump external wrapping of the ascending aorta with endovascular stent grafting of the aortic arch using an in-situ fenestration technique for treating type A IMH with PAU. This approach offers a minimally invasive alternative to open surgery, effectively addressing the anatomical challenges of this condition. Our case report demonstrates the feasibility and safety of this technique, as well as its favorable short-term outcomes. However, further studies with longer follow-up are needed to evaluate the efficacy and durability of this procedure, as well as to compare it with other treatment modalities.