Penetrating ulcers of the thoracic aorta: results from a single-centre experience

Endovascular repair of penetrating aortic ulcers: Indications and single-center mid-term results

BACKGROUND

Although endovascular repair is used to treat penetrating aortic ulcers (PAUs), the indications for endovascular repair in PAUs remain controversial. The current study evaluated the mid-term results of endovascular repair for PAUs and further explored the endovascular indications for PAUs.

METHODS

We retrospectively reviewed the clinical data of patients who were diagnosed with PAUs and underwent endovascular repair in our department from October 2018 to August 2020. Endovascular indication included persistent or recurring symptoms, a maximum diameter of the PAU of greater than 20 mm, a maximum depth of the PAU of greater than 10 mm, an increase in the diameter of the aorta at the ulcer of greater than 10 mm annually, and multiple ulcers at the same or adjacent level of the aorta. Patient characteristics, anatomical parameters of the PAU, characteristics of endovascular repair and follow-up data were analyzed.

RESULTS

Fifteen patients were included in the study. Three patients had PAUs in the aortic arch, 6 PAUs were in the descending thoracic aorta, 4 PAUs were in the abdominal aorta, and 2 PAUS were in the descending thoracic and abdominal aortas. The average age was 70.60±8.27 years. Eight patients were symptomatic. The average depth of the PAUs was 7.32±2.74 mm, and the average diameter was 15.03±6.10 mm. The average operation time was 95.60±33.11 min. Postoperative hospital stay was 3.33±0.61 days. A left subclavian artery chimney stent was implanted in 3 aortic arch cases and 1 occluded case without adverse symptoms during the follow-up period. A bifurcated stent graft was placed in 3 abdominal aorta cases and exhibited good patency during the follow-up period. The duration of follow-up ranged from 3 to 24 months. The follow-up results showed that all PAUs were treated satisfactorily by endovascular repair, and no endoleaks or stent graft-related complications occurred.

CONCLUSIONS

Endovascular repair is a safe and effective treatment for PAUs, and it may be safely performed in elderly patients and patients with comorbidities. The endovascular indications for PAUs must be further studied and optimized.

The Management of Patients With Penetrating Aortic Ulcers: A Systematic Review

BACKGROUND

Penetrating aortic ulcers (PAUs) are an entity within acute aortic syndrome. They often remain undiagnosed and are found incidentally or when they become symptomatic. Management is currently guided by clinical judgment. This review aims to identify indications for treatment and inform management.

METHODS

We searched PubMed for studies on the management of PAUs. The outcome measures were mortality, progression and resolution of symptoms.

RESULTS

This review incorporates 27 studies involving 1356 patients with PAU. Data was available regarding symptoms for 1213 patients (494 symptomatic, 719 asymptomatic). Overall late mortality for PAUs was found to be higher than 30-day mortality. Early mortality was higher for symptomatic patients as compared to those with asymptomatic PAUs. Early mortality was lowest for PAUs treated with endovascular interventions (5%), followed by PAUs managed medically and highest following open surgical management. Indications for treatment included symptoms, progression/instability, aortic diameter >5 cm, concomitant aortic pathology or pleural effusion. 13% of patients managed conservatively at initial presentation demonstrated progression and were considered for intervention subsequently. 9% of patients required reintervention after initial endovascular surgery.

CONCLUSION

Endovascular treatment, if anatomically suitable, should be considered as first line treatment for symptomatic PAUs. Patients with asymptomatic PAUs, if associated with high-risk features such as PAU diameter >20 mm, PAU depth >10 mm, aortic diameter >42 mm, concomitant pathology, morphological change or an infective etiology, should also be considered for intervention. Small asymptomatic PAUs with no high-risk features may be managed conservatively but must undergo regular surveillance.

Demystifying penetrating atherosclerotic ulcer of aorta: unrealised tyrant of senile aortic changes

This review article describes demographic features, comorbidities, clinical and imaging findings, prognosis, and treatment strategies in penetrating atherosclerotic ulcer (PAU) and closely related entities using google scholar web search. PAU is one of the manifestations of the acute aortic syndrome (AAS) spectrum. The underlying aorta invariably shows atherosclerotic changes or aneurysmal dilatation. Hypertension is the most common contributing factor, with chest or back pain being the usual manifestation. Intramural hematoma (IMH) is the second entity associated with both PAU and aortic dissection (AD), more so with the latter. Chest radiograph can show mediastinal widening, pleural, or pericardial fluid in rupture. Computed tomography angiography (CTA) is the imaging modality of choice to visualize PAU, with magnetic resonance imaging (MRI) and transoesophageal echocardiography (TEE) adding diagnostic value. Lesser-known entities of intramural blood pool (IBP), limited intimal tears (LITs), and focal intimal disruptions (FID) are also encountered. PAU can form fistulous communication with adjacent organs whereas IMH may propagate to dissection. CTA aids in defining the management, open or endovascular options in surgical candidates.

Penetrating Atherosclerotic Ulcer - an Increasingly Recognized Entity of the Acute Aortic Syndrome: Case Report and Literature Review

With the advance in diagnostic radiology, penetrating atherosclerotic ulcers of the aorta become increasingly recognised in our daily practice. However, their natural history and treatment are not well defined. We report a case of penetrating atherosclerotic ulcer at the aortic arch and review the literature.

Thoracic Endovascular Repair of Complicated Penetrating Aortic Ulcer

Purpose: To analyze an 11-year single-center experience of treating complicated penetrating aortic ulcer (PAU) using thoracic endovascular aortic repair (TEVAR). Methods: This study included 63 consecutive patients (mean age 69.1±11.5 years; 40 men) with complicated PAU (42 symptomatic, 22 with rupture) who underwent TEVAR between 2002 and 2013. The PAUs were located in the aortic arch (n=11), the descending thoracic aorta (n=43), and the thoracoabdominal aorta (n=9). Results: TEVAR was performed within 14 days of diagnosis in 33 (52.3%) cases (19 ruptures treated immediately); the other 30 (47.6%) patients had an average interval between diagnosis and intervention of 40±39 days. Technical success was 98.4% (62/63). One patient had a type I endoleak after stent-graft repair of a PAU in the aortic arch without great vessel transposition; another procedure was required for carotid-subclavian bypass and proximal stent-graft extension. No patient experienced spinal cord ischemia after TEVAR. Five (7.9%) patients died in-hospital; 3 had severe cardiac complications, 1 died from complications of aortic rupture, and the other succumbed to septic shock. Mean follow-up was 45.6±47.2 months, during which 12 (19.0%) patients needed a secondary intervention because of late endoleaks (n=4, 6.3%) or new complications due to disease progression. Multivariate analysis indicated that a PAU depth >15 mm was an independent predictor of mortality (hazard ratio 6.92, p=0.03). In the biomarker analysis, symptomatic patients had significantly higher D-dimer and troponin levels compared to asymptomatic patients [559.5±460.7 vs 283.2±85.2 µg/L (p=0.016) and 0.22±0.61 vs 0.02±0.03 ng/mL (p=0.04), respectively]. Conclusion: Patients with PAU suffer from underlying severe atherosclerotic disease and have a significant number of cardiovascular comorbidities that lead to relevant mortality and morbidity after TEVAR. As a PAU diameter >15 mm represented high risk for disease progression, these patients may be candidates for early intervention. D-dimer levels may help identify patients at risk and with progression of PAU.

Emergent repair of acute thoracic aortic catastrophes: a comparative analysis

OBJECTIVE

To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR).

DESIGN

Single-center retrospective review (April 2001-January 2010).

SETTING

Academic medical center.

PATIENTS

One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2).

MAIN OUTCOME MEASURES

Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months.

RESULTS

Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P < .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001).

CONCLUSION

Patients presenting with ACDTA are best treated with TEVAR whenever feasible.

Endovascular management of thoracic aortic pathology

BACKGROUND

Endovascular technology has revolutionised the management of abdominal aortic aneurysmal disease but the less frequent occurrence of pathology in the thoracic aorta has meant that evidence demonstrating the primacy of endovascular treatment strategies in this portion of the vessel is less convincing. Herein we summarise the best available evidence to date.

METHODS

A comprehensive search of the surgical and radiological literature using the search term 'endovascular thoracic aorta' was conducted.

FINDINGS AND CONCLUSIONS

The vast majority of patients treated by thoracic aortic stent grafting have had their treatment outside the context of a randomised trial. While it would seem that endovascular repair is the treatment of choice for the thoracic aorta, the present evidence is based on single centre case series and is anecdotal at best.

What to Do When Evidence is Lacking — Implications on Treatment of Aortic Ulcers, Pseudoaneurysms and Aorto-Enteric Fistulae

Present knowledge on natural history and how to treat penetrating aortic ulcers or different forms of pseudoaneurysms with or without infection is limited as there are only case reports and small series of unusual aortic pathology and its treatment available.

Material:

From our centre we collected 65 patients treated with open (n=15) or endovascular reconstruction (n=50) during a 20-year period in the abdominal aorta. These patients are presented including a review of contemporary treatment.

Results:

Endovascular reconstructions seem to reduce morbidity and mortality compared to otherwise extensive open surgery. Even for patients with infectious etiology (mycotic aneurysms, aorto-enteric fistula) endovascular treatment may be a first-hand option bridging to a more elective open repair. However, a large proportion of patients being unfit for further open surgery were solely treated endovascularly and had no major infectious complications in the follow-up. Registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.

Conclusion:

Endovascular technique is a promising technique for treatment of aortic pseudoaneurysms of different etiologies. We firmly recommend, despite the lack of evidence, that the work up of patients with penetrating aortic ulcers, mycotic or other types of pseudoanerysms as well as aorto-enteric fistulae should enclose both endovascular and open (or combined) treatment modalities. However, our knowledge of the natural history is limited. Therefore, registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.

Aortitis and Bacterial Endocarditis

Aortitis is an inflammatory condition that can be due to numerous causes. It is a diagnostic quandary because it commonly shows similar clinical, pathologic, and aortographic features independently of the etiology. A case of aortitis, possibly secondary to bacterial endocarditis, initially misdiagnosed as an atherosclerotic aortic ulcer and managed with an endoprosthesis is presented. On the fourth postoperative day, the patient presented with fever and worsening abdominal pain, which was later diagnosed as infectious aortitis. It required débridement and replacement of the infrarenal aorta with a cadaveric cryopreserved allograft. This case emphasizes the need for early diagnosis and aggressive therapy to avoid life-threatening sequelae.