Penetrating atherosclerotic ulcer of the abdominal aorta involving the celiac trunk origin and superior mesenteric artery occlusion: endovascular treatment

Isolated Ruptured Paravisceral Penetrating Aortic Ulcers

BACKGROUND

The goal of this study is to investigate the clinical presentation, treatment options, and outcomes of the patients with isolated ruptured paravisceral penetrating aortic ulcers (PV-PAU).

METHODS

All patients presenting with acute aortic syndrome from 2015 to 2020 were screened, of which patients with isolated ruptured PV-PAU were included in this retrospective study. Study endpoints were the assessment of treatment options, technical success, and clinical outcome. Outcome measures included major perioperative complications and mortality.

RESULTS

Sixteen patients (11 men; median age 68; IQR 60 - 75 years) presented with isolated ruptured PV-PAU were included in this study. The median follow-up was 25 months (range 1 - 51). Ruptured PV-PAUs represented 12.3% of the ruptured aortic aneurysms in all locations. PV-PAUs were found in segment A (n = 8, 50%), segment B (n = 5, 31%), and segment C (n = 3, 19%). PV-PAUs showed a mean protrusion distance of 27±10 mm, a mean neck diameter of 21 ± 7 mm, and maximal aortic diameter of 50 ± 11 mm. Five patients (31%) showed hemodynamic instability on admission and needed intense fluid resuscitation. Of those, 2 patients needed urgent laparotomy with a fast transabdominal supraceliac aortic clamping, one needed an aortic balloon occlusion to obtain rapid aortic control. The open aortic repair was the most frequently performed surgery (11/16, 69%), followed by hybrid procedures (3/16) and parallel graft chimney technique (2/16). Two patients died during the follow-up, calculating for in-hospital and 1-year mortality rates of 6 - 12%, respectively. The postoperative morbidity rate was 31%. Postoperative complications included acute renal failure (31%), pneumonia (25%), and 1case of ischemic colitis (6%). No spinal cord ischemia was reported.

CONCLUSIONS

Ruptured PV-PAU is a rare and challenging diagnostic and therapeutic entity. Open aortic repair seems to be a reliable option in treating patients with isolated ruptured PV-PAUs. Hybrid procedures and parallel stent-graft techniques can only be used in selected patients.

Penetrating Atherosclerotic Ulcers of the Abdominal Aorta: A Case Report and Review of the Literature

Penetrating atherosclerotic ulcers (PAUs) of the aorta are defined as atherosclerotic lesions with aortic intima and media ulceration, which may lead to a complete rupture of the adventitial wall. The present article aimed to report an unusual case of a surgically treated patient with abdominal aorta PAU with an illustration of the key features and to review and analyze the existing literature data. PAUs typically develop in elderly and hypertensive patients and in patients with advanced atherosclerosis. Although originally described for the descending thoracic aorta, a similar clinicopathological entity also occurs in the abdominal aorta. Patients with symptoms of a PAU should be treated immediately if they are fit for surgery. Exceptive observation by imaging modalities is necessary in patients with asymptomatic small (<2 cm) PAU, with or without focal dissection.

Abdominal aorta aneurysm with hostile neck: Early outcomes in outside instruction for use in patients using the treovance® stent graft

Purpose:

The efficacy and safety of endovascular aneurysm repair (EVAR), in patients outside instruction for use (IFU), is very challenging and widely debated. The aim of this study was to evaluate the placement of the Treovance^® abdominal aorta stent-graft in patients with hostile proximal necks considered outside IFU.

Materials and Methods:

Between May 2013 and August 2014, 5 patients with outside IFU underwent EVAR with the Treovance^® stent-graft. Technical and clinical successes were evaluated. All 5 patients underwent clinical and imaging follow-up.

Results:

Technical and clinical successes were achieved in all 5 patients without adjunctive endovascular procedures or surgical conversion. During the mean follow-up of 21 months, no type I/III endoleaks, stent-graft migration nor kinking/occlusion were observed. In all 5 patients, a reduction of the proximal neck angle was observed.

Conclusion:

In our small series of selected outside IFU patients, EVAR with the Treovance^® stent-graft was technically feasible and safe, with satisfactory short-term follow-up results, when performed by experienced operators. Long-term follow-up will be necessary to confirm the durability of our preliminary promising results.

Spontaneous Rupture of Abdominal Aorta after Seizure in a 23-Year-Old Woman: A Case Report

Spontaneous non-aneurysmal aortic rupture is a rare and life threatening clinical entity. A 23-year-old female patient who visited a nearby hospital due to intractable seizure was transferred to our hospital with the impression of hypotension and decreased level of haemoglobin. She had a history of seizure attacks once a month. However, in the 2 weeks before presentation, the frequency of seizure attacks had increased to 2 to 3 times a day. An abdominal-pelvic computed tomogram scan showed extravasation of contrast from the abdominal aorta at L3 level. An emergency laparotomy revealed a 0.3 cm diameter tear in the posterior wall of the aorta, superior to the iliac bifurcation. We discuss the mechanism of spontaneous aortic rupture and the possibility of aortic rupture related to seizure attacks. (Hong Kong j.emerg.med. 2014;21:103-106)

Endovascular treatment of penetrating ulcers of the paraceliac aorta using fenestrated endografts

Penetrating atherosclerotic ulcers (PAUs) are usually focal aortic lesions found in patients with significant comorbidities. They are ideal targets for an endovascular approach if localized in the descending thoracic or infrarenal aorta, but when an origin in the visceral vessels is involved, a standard endovascular approach might not be feasible or effective. We report 2 cases of endovascular treatment of PAUs involving the paraceliac abdominal aorta, using a custom-made tube fenestrated endograft with 4 fenestrations for the abdominal visceral vessels (i.e., celiac-trunk, superior mesenteric artery, and renal arteries). There were no intra- or perioperative complications. At 1 year of follow-up, patients were asymptomatic and computed tomography angiography revealed total lesion exclusion and patency of the visceral vessels. The use of a fenestrated endograft is a safe and effective option to treat paraceliac PAUs.