The association of repair timing on outcomes following thoracic endovascular aortic repair for intramural hematoma

Objective: 

Intramural hematoma (IMH) carries significant risk of morbidity and mortality, and although thoracic endovascular aortic repair (TEVAR) is increasingly used as a treatment, the optimal timing for its intervention remains uncertain. This study aimed to compare outcomes between patients undergoing urgent TEVAR (within 24 hours of admission) and those undergoing elective TEVAR (beyond 24 hours from admission). 

Methods: 

Patients who underwent TEVAR between aortic zones 2 and 5 for IMH from 2013 to 2023 were included, excluding those with rupture. Propensity scores were generated using covariates such as age, sex, race, obesity, anemia, transfer status, hypertension, diabetes, prior myocardial infarction, congestive heart failure, smoking history, chronic obstructive pulmonary disease, cerebrovascular disease, dialysis status, medication use, and previous aortic surgery, to adjust for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes were assessed using inverse probability-weighted logistic regression. Association of urgent or elective TEVAR with 5-year mortality was assessed using Cox regression stratified by IMH symptom status. 

Results: 

Among 345 patients, 165 (48%) underwent elective repair. The urgent group had a higher rate of transfers from outside institutions (64% vs 43%; P = .01), were less likely to use beta-blockers before presentation (69% vs 84%; P = .003), and were more frequently symptomatic at presentation (98% vs 72%; P < .001). There were no significant differences in IMH disease extent or graft landing zones between groups. Perioperative mortality (6.3% vs 0.6%; adjusted odds ratio [aOR] 19; 95% confidence interval [CI], 3.01-764; P = .02) and reintervention during index admission (8.3% vs 2.4%; aOR, 4.92; 95% CI, 1.67-19.5; P = .01) was significantly greater in the urgent group. Five-year survival was lower in the urgent group, but this difference was not statistically significant. In symptomatic patients, the urgent cohort had significantly higher perioperative mortality (7.3% vs 0.8%; aOR, 10; 95% CI, 2.11-152; P = .02), acute kidney injury (9.0% vs 2.5%; aOR, 3.28; 95% CI, 1.12-12.1; P = .04), and reintervention (8.5% vs 2.5%; aOR, 5.26; 95% CI, 1.61-25.6; P = .01) rates. Conversely, the elective group had a longer total length of stay (32% vs 21%; aOR, 0.48; 95% CI, 0.28-0.82; P = .01). Five-year survival in the symptomatic cohort was lower in the urgent group, but this difference was not statistically significant.

Conclusions: 

Patients undergoing urgent TEVAR for IMH experience worse perioperative outcomes compared with those undergoing elective repairs, despite comparable baseline risk profiles. Although emergent repair may be necessary in certain cases, these data advocate for a patient management strategy that prioritizes stabilization before intervention.