Natural history and clinical significance of aortic focal intimal flaps

Austin Maas; Pieter A J van Bakel; Yunus Ahmed; Himanshu J Patel; Nicholas S Burris

doi:10.3389/fcvm.2022.959517

Natural history and clinical significance of aortic focal intimal flaps

Front Cardiovasc Med. 2022 Oct 4:9:959517. doi: 10.3389/fcvm.2022.959517. eCollection 2022.

Authors

Austin Maas¹, Pieter A J van Bakel^{2

3}, Yunus Ahmed^{2

3}, Himanshu J Patel², Nicholas S Burris¹

Affiliations

¹ Department of Radiology, University of Michigan, Ann Arbor, MI, United States.
² Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States.
³ Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands.

Abstract

Objective: Focal intimal flaps (FIF) are a variety of defects of the aorta that result in a short, flap-like projection into the lumen, and are often encountered in asymptomatic patients undergoing computed tomography angiography (CTA) surveillance for aortic aneurysm, but the natural history and clinical significance of such lesions has not yet been studied.

Methods: We retrospectively identified patients with an asymptomatic FIF and available imaging follow-up (>1 year). FIF was defined as flap-like intimal irregularity < 4 cm in length involving the thoracic aorta (TA), abdominal aorta (AA) or common iliac arteries (CIA). FIF characteristics included length and circumferential extent as well as the presence and size (width and depth) of associated penetrating aortic ulcers (PAUs). Patient characteristics, adverse events and history of surgical repair was determined by chart review. FIFs and associated PAUs were assessed for progression by comparing baseline and follow-up CTA studies.

Results: A total of 84 FIFs were identified in 77 patients. Average age was 69.2 ± 10.1 years, and 81% were male (81%). Common co-morbidities included: hypertension (78%), hyperlipidemia (68%), smoking (60%), coronary artery disease (41%), aortic aneurysm (34%), type II diabetes mellitus (27%) and prior cardiovascular surgery (25%). FIFs were most commonly located in the abdominal aorta (n = 50, 60%). Nearly all FIFs were associated with local atherosclerotic plaque (93%). Mean follow-up interval was 3.5 ± 2.6 years (259 cumulative follow-up years). Change in FIF length and local aortic diameter over follow-up were 0.7 ± 2.3 mm and 0.8 ± 1.1 mm, respectively. Nearly half (47%) of FIFs were associated with penetrating aortic ulcers (PAU) with baseline depth of 7.3 mm (IQR: 6.1-10.2) and change in depth of 0.5 ± 1.4 mm. Only 12% of FIFs and 0% of associated PAUs demonstrated growth (≥3 mm) at follow-up. No acute pathology developed in the location of FIFs and no aortic interventions were performed specifically to treat FIFs.

Conclusion: Focal intimal flaps identified in asymptomatic patients with aortic disease were co-localized with atherosclerotic plaque and PAUs, and demonstrated indolent behavior, not leading to significant growth or acute aortic events, supporting a conservative management approach.

Keywords: aortic disease; aortic dissection; atherosclerosis; intimal flap; penetrating atherosclerotic ulcer (PAU).