The challenge of associated intramural hematoma with endovascular repair for penetrating ulcers of the descending thoracic aorta Himanshu J. Patel, MD,

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The challenge of associated intramural hematoma with endovascular repair for penetrating ulcers of the descending thoracic aorta Himanshu J. Patel, MD, David M. Williams, MD, Gilbert R. Upchurch, MD, Narasimham L. Dasika, MD, G. Michael Deeb, MD Journal of Vascular Surgery Volume 51, Issue 4, Pages 829-835 (April 2010) DOI: 10.1016/j.jvs.2009.11.050 Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 1 Cumulative survival is shown for patients undergoing elective (solid line) and urgent or emergent (dashed line) thoracic endovascular aneurysm repair. Seven year actuarial survival was 84.4% ± 10.2% for elective operation vs 46.2% ± 11.4% for urgent or emergent operation. Operative status was also identified as an independent risk factor for late all cause mortality on multivariate analysis (P = 0.006). Journal of Vascular Surgery 2010 51, 829-835DOI: (10.1016/j.jvs.2009.11.050) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 2 Kaplan-Meier analysis shows freedom from aortic reintervention, rupture, or aortic-related death during the 84-month follow-up. Journal of Vascular Surgery 2010 51, 829-835DOI: (10.1016/j.jvs.2009.11.050) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 3 Kaplan-Meier analysis shows (A) cumulative survival and (B) freedom from aortic reintervention, rupture, or aortic-related mortality for patients with penetrating aortic ulcer (PAU, solid line) and patients with PAU and intramural hematoma (IMH; dashed line). Journal of Vascular Surgery 2010 51, 829-835DOI: (10.1016/j.jvs.2009.11.050) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 4 This patient illustrates both the principle of TEVAR failure when performed for PAU with IMH (ie, proximal landing zone), and also describes the evolution of a new entry tear at the distal landing zone in the absence of any intervention. He presented with a PAU and IMH while waiting for repair of a large infrarenal AAA (A), and underwent treatment of the PAU with a short segment Talent endograft (B). The stent graft was oversized by 5-10%, and balloon dilation at the landing zones was avoided. A new entry tear was identified at the proximal landing zone on a follow-up CT scan at 30 days (C). Over the ensuing 15 months, the patient developed a new tear at the distal landing zone with growth of the aorta (D at 5 months, and E at 13 months). He eventually expired from complications of liver failure while awaiting repeat TEVAR. Journal of Vascular Surgery 2010 51, 829-835DOI: (10.1016/j.jvs.2009.11.050) Copyright © 2010 Society for Vascular Surgery Terms and Conditions