The Management of Penetrating Aortic Ulcer

Abstract

Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management.

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

“…2,[4][5][6][8][9]16,18,23,33,55 TEVAR is preferable in patients showing signs and symptoms of abdominal or limb ischemia, those with associated infectious aortitis especially mycotic and anatomical abnormality like coarctation. 18, 76 Cho et al suggested medical management for PAU and also expected resolution of IMH with time. 5 This approach was supported by other studies in regard to asymptomatic cases and those involving descending aorta.…”

“…5 This approach was supported by other studies in regard to asymptomatic cases and those involving descending aorta. 12,17,36,46,76 When the IMH is seen in concurrence with PAU, urgent surgical management is an absolute indication in cases of Type A IMH. For Type B IMH the indications remain more or less the same as those for PAU.…”

“…4,7,45 Aortic tissue in patients with PAU is usually friable, making open graft repairs difficult. 76 Relatively normal aortic morphology on either side of the ulcer facilitates acquiring landing zones for better graft stability. 42 The minimum length of this landing zone required is 1.5-2 cm at either end.…”

“…TEVAR also has a particular advantage in cases of paravisceral PAU, with the placement of branching grafts. 76 Stent-graft is at a certain disadvantage in cases of PAU complicated by the formation of aortoenteric fistula, leading to graft infection and potential recurrence of fistulous communication. In such cases, endovascular procedure plays the role of an intermediate step bridging acute presentation with the definite open surgical treatment performed at a later date.…”

Anesthetic management of endovascular repair of penetrating ulcer of descending thoracic aorta

“…This research is currently lacking, and larger studies or registries may be helpful in optimizing PAU management. [ 6 ] Future studies are required to have more definitive management protocols for such cases.…”