1
|
Wolk S, Prange LS, Kapalla M, Schaab F, Weiss N, Hoffmann RT, Reeps C. Midterm survival after aortic repair versus conservative treatment in patients with penetrating aortic ulcer. VASA 2024; 53:255-262. [PMID: 38874211 DOI: 10.1024/0301-1526/a001128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Background: The clinical outcomes and survival of patients with penetrating aortic ulcers (PAU) were evaluated in a tertiary care hospital, comparing those who underwent aortic repair to those treated conservatively. Patients and methods: A retrospective single-centre analysis included all patients that underwent a computed tomography angiography (CT-A) scan with the diagnosis of a PAU between January 2009 and May 2019. "PAU" was identified in 1,493 of 112,506 CT-A scan reports in 576 patients. Clinical and angiomorphological data were collected. The primary outcome was overall survival (OS), with secondary outcomes focusing on identifying risk factors for poor OS. Survival probabilities were analysed by the Kaplan-Meier method using the log-rank test. A Cox hazard model using survival as dependent variable with stepwise backward eliminations based on the likelihood ratios was employed. Results: 315 PAUs were identified in 278 patients. The prevalence in the cohort was 0.8%. The mean age of the patients was 74.4 years, and they were predominantly male (n = 208, 74.8%). The mean ulcer depth was 11.8 mm (range 2-50 mm). Out of the patients, 232 were asymptomatic (83.5%). Among 178 PAUs (56.5%), high-risk factors, such as ulcer depth >10 mm, aortic diameter >40 mm, and ulcer length >20 mm, were observed. Aortic repair was associated with a better mean OS compared to conservatively managed patients (72.6 versus 32.2 months, p = 0.001). The Cox hazard model showed that ulcer depth >1 mm was associated with poor OS (HR 0.67, p = 0.048), while aortic repair was related to a better OS (HR 4.365, p<0.013). Conclusions: Aortic repair is associated with better OS, but this finding should be interpreted with caution because of differences in age and comorbidities between the groups. Further evaluation is warranted through prospective studies with randomized groups. Further assessment for angiomorphological parameters is recommended to identify patients at increased risk for poor OS.
Collapse
Affiliation(s)
- Steffen Wolk
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Lena-Sophie Prange
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Marvin Kapalla
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Felix Schaab
- Medizinische Fakultät Carl Gustav Carus, Institute for Diagnostic and Interventional Radiology, Technische Universität Dresden, Germany
| | - Norbert Weiss
- Division of Angiology, Department of Internal Medicine III, University Center for Vascular Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Medizinische Fakultät Carl Gustav Carus, Institute for Diagnostic and Interventional Radiology, Technische Universität Dresden, Germany
| | - Christian Reeps
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| |
Collapse
|
2
|
Grigorescu AE, Anghel A, Feier H. Successful Interventional Endovascular Management of Ruptured Penetrating Aortic Ulcer with Associated Enormous Right Pleural False Aneurysm. Clin Pract 2024; 14:619-628. [PMID: 38666807 PMCID: PMC11049587 DOI: 10.3390/clinpract14020049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/24/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Penetrating aortic injuries represent critical medical emergencies that necessitate immediate intervention to prevent life-threatening consequences. When accompanied by the presence of an enormous right pleural false aneurysm, the clinical scenario becomes exceptionally rare and complex. This case report details the successful management of a patient who presented with a penetrating aortic ulcer and an extensive false aneurysm within the right pleura, employing an interdisciplinary approach involving cardiac surgeons, cardiologists, interventional cardiologists, and radiologists. The pivotal intervention involved the deployment of a covered and bare stent graft into the descending thoracic aorta to seal the aortic rupture. The patient's clinical condition stabilized postoperatively, with no signs of recurrent hemorrhage. This case underscores the importance of rapid diagnosis, timely intervention, and the collaborative efforts of a specialized medical team in successfully managing such complex vascular injuries. Early recognition and referral to specialized centers are essential for improving patient outcomes in cases of penetrating aortic injuries with associated giant pseudoaneurysms.
Collapse
Affiliation(s)
- Andrei Emanuel Grigorescu
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (A.E.G.); (H.F.)
- Research Center of the Institute of Cardiovascular and Heart Disease of Timisoara, 300310 Timisoara, Romania
- Division of Cardiovascular Surgery, Institute for Cardiovascular Diseases, 300391 Timisoara, Romania
- Doctoral School Medicine—Pharmacy, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
| | - Andrei Anghel
- Department of Biochemistry, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
| | - Horea Feier
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (A.E.G.); (H.F.)
- Research Center of the Institute of Cardiovascular and Heart Disease of Timisoara, 300310 Timisoara, Romania
- Division of Cardiovascular Surgery, Institute for Cardiovascular Diseases, 300391 Timisoara, Romania
| |
Collapse
|
3
|
Kimura Y, Nakamura K, Kojima D, Katayama T, Takarabe S, Kishikawa H, Sasaki A, Hisamatsu T, Nishida J. Life-threatening gastrointestinal bleeding caused by perforation of a penetrating atherosclerotic ulcer into the esophagus. Clin J Gastroenterol 2023; 16:815-821. [PMID: 37695416 DOI: 10.1007/s12328-023-01856-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
We present a case of life-threatening gastrointestinal bleeding caused by a penetrating atherosclerotic ulcer (PAU) that ruptured into the esophagus. A 65-year-old man presented with pyrexia and nausea. Contrast-enhanced computed tomography (CT) performed on admission revealed a hematoma between the lower esophagus and descending aorta due to a contained rupture of a PAU, which was undiagnosed at that time. Esophagogastroduodenoscopy (EGD) performed on the fifth day of admission revealed a subepithelial lesion in the lower esophagus, further complicated by ulcer formation. Biopsy did not reveal any malignant findings. On the eighth day of admission, the patient experienced substantial hematemesis with vital signs indicative of shock. Emergency EGD was performed, which revealed life-threatening bleeding in the lower esophagus. Contrast-enhanced CT revealed an aortoesophageal fistula with massive hematemesis, after which the patient died. An autopsy revealed perforation of the PAU into the esophagus without aortic dissection or a true aneurysm.Patients with atherosclerosis who develop recent-onset gastrointestinal symptoms, progressive anemia, and/or periaortic lesions should be carefully evaluated using contrast-enhanced CT, and PAU should be considered in the differential diagnosis.
Collapse
Affiliation(s)
- Yoko Kimura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Tokyo Dental College, Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan
| | - Kenji Nakamura
- Department of Gastroenterology, Tokyo Dental College, Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan.
| | - Daiki Kojima
- Department of Endocrinology, Metabolism, and Nephrology, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Katayama
- Department of Gastroenterology, Tokyo Dental College, Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan
| | - Sakiko Takarabe
- Department of Gastroenterology, Tokyo Dental College, Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan
| | - Hiroshi Kishikawa
- Department of Gastroenterology, Tokyo Dental College, Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan
| | - Aya Sasaki
- Department of Clinical Laboratory, Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Jiro Nishida
- Department of Gastroenterology, Tokyo Dental College, Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan
| |
Collapse
|
4
|
Shao T, Bornak A, Kang N. Penetrating aortic ulcer and aortic intramural hematoma: Treatment strategy. Vascular 2023; 31:1086-1093. [PMID: 35578772 DOI: 10.1177/17085381221102785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The indication, timing, and choice of the treatment modality for penetrating aortic ulcers (PAUs) and intramural hematoma (IMH) are frequently challenging. This article reviews these pathologies and their relation to aortic dissection and proposes a diagnostic and treatment algorithm. METHODS A review of literature on diagnosis and treatment of PAU and IMH was conducted. The PubMed database was searched using the terms "penetrating aortic ulcer" and "aortic intramural hematoma". Articles were reviewed and the studies involving diagnosis and management of PAU and IMH were included. We subsequently proposed a management algorithm for PAU and IMH based on available evidence. RESULTS PAU and IMH are distinct entities from aortic dissection, although they carry a significant risk of progression into dissection, aneurysm, and rupture. PAU and IMH originating in zone 0 of the aorta generally require surgical treatment. When the origin is beyond zone 0, a trial of medical therapy is recommended. Progression of disease on imaging studies, persistent uncontrolled pain, and certain high-risk features warrant surgery. High-risk features signaling risk of disease progression include PAU with IMH, PAU depth more than 10 mm, PAU diameter more than 20 mm, IMH thickness more than 10 mm, and maximum initial aortic diameter more than 40 mm. CONCLUSIONS High-quality evidence regarding the treatment of PAU and IMH is lacking. These entities can have a malignant course when they are present with associated symptoms and/or when they have associated high-risk features on imaging. An aggressive surgical approach is necessary in that group of patients.
Collapse
Affiliation(s)
- Tony Shao
- Division of Vascular and Endovascular Surgery, University of Miami, Miami, FL, USA
| | - Arash Bornak
- Division of Vascular and Endovascular Surgery, University of Miami, Miami, FL, USA
| | - Naixin Kang
- Division of Vascular and Endovascular Surgery, University of Miami, Miami, FL, USA
| |
Collapse
|
5
|
Garg I, Grist TM, Nagpal P. MR Angiography for Aortic Diseases. Magn Reson Imaging Clin N Am 2023; 31:373-394. [PMID: 37414467 DOI: 10.1016/j.mric.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Aortic pathologic conditions represent diverse disorders, including aortic aneurysm, acute aortic syndrome, traumatic aortic injury, and atherosclerosis. Given the nonspecific clinical features, noninvasive imaging is critical in screening, diagnosis, management, and posttherapeutic surveillance. Of the commonly used imaging modalities, including ultrasound, computed tomography, and MR imaging, the final choice often depends on a combination of factors: acuity of clinical presentation, suspected underlying diagnosis, and institutional practice. Further research is needed to identify the potential clinical role and define appropriate use criteria for advanced MR applications such as four-dimenional flow to manage patients with aortic pathologic conditions.
Collapse
Affiliation(s)
- Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1 University Of New Mexico, Albuquerque, NM 87131, USA
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin-Madison, E3/366 Clinical Science Center 600 Highland Avenue Madison, WI 53792, USA
| | - Prashant Nagpal
- Cardiovascular and Thoracic Radiology, University of Wisconsin School of Medicine and Public Health, E3/366 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA.
| |
Collapse
|
6
|
Clay KJ, Campbell WF, Lowe CE, Protos AN, Coimbatore Jeyakumar AK. Ruptured Penetrating Atherosclerotic Ulcer Repaired With an Amplatzer Atrial Septal Occluder. Cureus 2023; 15:e37641. [PMID: 37200646 PMCID: PMC10187796 DOI: 10.7759/cureus.37641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 05/20/2023] Open
Abstract
Ascending aortic pseudoaneurysms are an infrequent but life-threatening complication of cardiac and aortic surgery. Although rare, these pseudoaneurysms can form as a complication of penetrating atherosclerotic ulcers. We report a case of a ruptured penetrating atherosclerotic ulcer repaired percutaneously with an Amplatzer Atrial Septal Occluder (Abbott, Plymouth, MN, USA).
Collapse
Affiliation(s)
- Kyle J Clay
- Department of Medicine, University of Mississippi Medical Center, Jackson, USA
| | - William F Campbell
- Division of Cardiovascular Diseases, University of Mississippi Medical Center, Jackson, USA
| | - Catherine E Lowe
- Division of Cardiovascular Diseases, University of Mississippi Medical Center, Jackson, USA
| | - Adam N Protos
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, USA
| | | |
Collapse
|
7
|
Xu X, Lu F, Li L. Thoracic endovascular aortic repair and optimal medical treatment for acute type B penetrating aortic ulcer associated with intramural hematoma. Medicine (Baltimore) 2022; 101:e31301. [PMID: 36397387 PMCID: PMC9666100 DOI: 10.1097/md.0000000000031301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
To compare the safety and efficacy of thoracic endovascular aortic repair (TEVAR) and optimal medical treatment (OMT) for type B penetrating aortic ulcer (PAU) associated with intramural hematoma (IMH). From January 2015 to December 2018, 68 consecutive patients with acute type B PAU associated with IMH were enrolled in the study. TEVAR was performed following initially OMT in 30 patients (group A), and OMT was performed in 38 patients (group B). Primary outcome was aortic-related mortality. Secondary outcomes included all-cause mortality, aortic-related adverse events, and complete aortic remodeling. There was no significant difference in the baseline characteristics of patients among the 2 groups except for the depth of PAU and the thickness of IMH. Patients in group B had a significant higher risk of aortic-related mortality (13.3% vs 0%, P = .045), as the same to aortic-related adverse events during follow-up. Compared to OMT, TEVAR contributed to the favorable aortic remodeling more significantly during the mid-term follow-up (85.7% vs 18.2%, P < .001). Comparing with optimal medical repair, TEVAR for patients with PAU associated with IMH could promote the favorable aortic remolding more significantly and result in lower aortic-related mortality during mid-term follow-up. It should be considered as the first-line therapeutic option when intervention is required.
Collapse
Affiliation(s)
- Xiuchun Xu
- Department of General Surgery, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
| | - Feng Lu
- Department of General Surgery, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
| | - Li Li
- Department of Clinical Laboratory, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
- * Correspondence: Li Li, Department of Clinical Laboratory, Binhai People’s Hospital, Yancheng, Jiangsu Province 224500, People’s Republic of China (e-mail: )
| |
Collapse
|
8
|
Colacchio EC, Squizzato F, Piazza M, Menegolo M, Grego F, Antonello M. Clinical and Imaging Predictors of Disease Progression in Type B Aortic Intramural Hematomas and Penetrating Aortic Ulcers: A Systematic Review. Diagnostics (Basel) 2022; 12:2727. [PMID: 36359569 PMCID: PMC9689060 DOI: 10.3390/diagnostics12112727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/29/2022] [Accepted: 11/06/2022] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND This work aims to review recent literature on penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs), in order to identify clinical and imaging factors connected to aortic-related adverse events (AAE). METHODS We performed a systematic review according to the Preferred Reporting Items for Systematic review and Metanalyses (PRISMA) guidelines. An electronic search was conducted on Medline and Embase databases. We included articles reporting on PAUs and/or IMHs localized in the descending thoracic and/or abdominal aorta and analyzing clinical and/or radiological markers of AAE. RESULTS Of 964 records identified through database searching, 17 were incorporated in the present review, including 193 and 1298 patients with type B PAUs and IMHs, respectively. The 30-days aortic-related mortality (ARM) was 4.3% and 3.9% for PAUs and IMHs. A total of 21% of patients with IMHs underwent intervention during the follow-up period, and 32% experienced an AAE. PAU markers of AAE were minimum depth (ranging from 9.5 to 15 mm) and diameter (≥12.5 mm). Maximum aortic diameter (MAD) cut-off values ranging from 38 to 44.75 mm were related to AAE for IMHs, together with ulcer-like projection (ULP) of the aortic wall. CONCLUSIONS Despite data heterogeneity in the literature, this PAU- and IMH-focused review has highlighted the imaging and clinical markers of disease progression, thus identifying patients that could benefit from an early intervention in order to reduce the AAE rate.
Collapse
Affiliation(s)
- Elda Chiara Colacchio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Section, University of Padova, Azienda Ospedale-Università di Padova, 35128 Padova, Italy
| | | | | | | | | | | |
Collapse
|
9
|
Huang D, Huttleston A, Fraunfelter F, Leon LN, Ganti L. Penetrating Aortic Ulceration With Pseudoaneurysm and Intramural Hematoma: Emergency Department Management and Point-of-Care Ultrasound Diagnosis. Cureus 2022; 14:e27536. [PMID: 36060360 PMCID: PMC9427664 DOI: 10.7759/cureus.27536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 11/14/2022] Open
Abstract
Penetrating aortic ulcer (PAU) complicated by an intramural hematoma is a rare and potentially life-threatening emergency department (ED) presentation that is defined by progressive ulceration through the intima layer into the media layer of the aorta. Symptomatic PAUs can be clinically indistinguishable from other life-threatening pathologies such as aortic dissection, acute coronary syndrome (ACS), intrabdominal catastrophes as well as less lethal processes such as musculoskeletal back pain. Given the potential of PAUs to result in lethal aortic
rupture and dissection, the emergency provider should maintain a high index of suspicion in patients with risk factors for aortic pathologies and utilize diagnostic modalities such as point-of-care ultrasound (POCUS) to expedite diagnosis.
Collapse
|
10
|
Beckerman WE, Lajos PS. Management of Acute Aortic Syndromes. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
11
|
Murana G, Di Marco L, Fiorentino M, Buia F, Brillanti G, Lovato L, Pacini D. Endovascular treatment of penetrating atherosclerotic ulcers of the arch and thoracic aorta: In-hospital and 5-year outcomes. JTCVS OPEN 2022; 10:12-21. [PMID: 36004263 PMCID: PMC9390477 DOI: 10.1016/j.xjon.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 03/01/2022] [Indexed: 11/24/2022]
Abstract
Objective Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic aorta diseases including penetrating aortic ulcer (PAU). The objective of this study was to analyze the results of TEVAR for the treatment of PAU in our population. Methods From January 1999 to January 2019, 830 patients with type B aortic syndromes were treated with TEVAR in our institution. Of these we selected 73 patients treated for a PAU. Clinical and radiologic follow-up was performed in all patients. Results Mean age of our population was 72 ± 8 years. Fifteen patients (20.5%) were treated in an emergency setting. The proximal landing zone was in arch zone 2 in 22 patients (30.1%). In-hospital mortality was 6.8% and was associated with acute presentation (P = .005). Distal arch delivery of the endograft was unrelated to mortality (Fisher exact test, P = .157). Survival at 1 and 5 years was 81.7% and 67.3%, respectively. Sixteen patients underwent reintervention of the thoracic aorta. Patients who underwent emergency surgery and older patients had a shorter survival (log rank test, P < .001). No difference in survival was shown according to the proximal landing zone (log rank P = .292) or the dimension of the thoracic aorta (log rank P = .067). In multivariable Cox regression analysis, only age older than 75 years was associated with 5-year mortality (hazard ratio, 6.60; 95% CI, 2.12-20.56); P < .001). Conclusions The use of TEVAR for treatment of aortic PAU is a safe procedure in an elective setting despite necessity of arch stent grafting. An early intervention performed at smaller aortic diameters of <55 mm might be beneficial in selected patients to improve late survival.
Collapse
|
12
|
Penetrating Aortic Ulceration Treated with Castor Branched Aortic Stent Graft—A Case Series. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084809. [PMID: 35457675 PMCID: PMC9033075 DOI: 10.3390/ijerph19084809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/28/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
Penetrating aortic ulceration (PAU) is an acute aortic syndrome similar to aortic dissection and intramural hematoma. It is the result of a tunica intima ulceration due to atherosclerotic disease. This clinical condition can lead to serious complications and a poor short-term prognosis, especially in high-surgical-risk patients. We report three cases of patients referred to “Ospedale del Cuore” of Massa (Italy) with PAU at the aortic arch-proximal descending aorta level who could not undergo surgical intervention. For the first time in Italy, we successfully treated these patients with a full percutaneous implantation of a Castor branched aortic stent graft. Our case series shows that this type of endovascular graft is an effective, safe, and feasible treatment for PAU involving a distal aortic arch and avoiding surgery and related complications.
Collapse
|
13
|
Wang S, Liu D, Li Y, Gao B. Transthoracic minimally invasive closure for the treatment of arch penetrating aortic ulcer: a case report. J Cardiothorac Surg 2021; 16:285. [PMID: 34627316 PMCID: PMC8501624 DOI: 10.1186/s13019-021-01659-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/19/2021] [Indexed: 11/24/2022] Open
Abstract
Penetrating aortic ulcer (PAU) is one of the three subtypes of acute aortic syndrome. PAUs occur at any point throughout the aorta, most commonly in the descending thoracic aorta and less frequently in the aortic arch. Open surgical repair and total/hybrid endovascular repair are currently available to treat aortic arch PAUs. Herein, we present a patient with aortic arch PAU who underwent transthoracic minimally invasive closure, which is a novel method for the treatment of PAU. We describe a 52-year old Asian man who presented with sudden chest and back pain for 8 h. Computed tomography angiography showed that the PAU occurred in the aortic arch and had a diameter of 16 mm and a depth of 6 mm. The opening was successfully closed via transthoracic minimally invasive closure with an atrial septal defect occluder.
Collapse
Affiliation(s)
- Shixiong Wang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu, People's Republic of China
| | - Debin Liu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu, People's Republic of China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu, People's Republic of China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu, People's Republic of China.
| |
Collapse
|
14
|
Meharban N, Munir W, Idhrees M, Bashir A, Bashir M. Management of the penetrating atherosclerotic ulcer in the descending thoracic aorta. Asian Cardiovasc Thorac Ann 2021; 29:661-668. [PMID: 34397303 DOI: 10.1177/02184923211033166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Penetrating atherosclerotic ulcers present with an insidious onset with a reported mortality of 9%, varying across populations. With vast arrays of risk factors and potentially ominous complications, it is vital to efficiently provide optimum strategies for management. There exists controversy in the literature regarding management, especially for Type B penetrating atherosclerotic ulcers; the decision-making framework encompasses numerous factors in considerations for medical management versus invasive intervention and choice of endovascular versus open repair in the latter. The concomitant presence of intramural haematoma adds further complexity to the already intricate decision-making for management. We performed searches through PubMed and SCOPUS analysing studies reporting outcomes for management strategies for penetrating atherosclerotic ulcers treatment, focusing on Type B, further seeking to analyse studies reporting their experiences of PAU patients with concomitant intramural haematoma. Our review highlights the ambiguity and controversy existing in the literature, comprising studies burdened by their inherent hindering limitations of their single-centre retrospective experiences. Endovascular therapy has come to the forefront of penetrating atherosclerotic ulcers management, often considered first line therapy. In the case of penetrating atherosclerotic ulcers alongside intramural haematoma, there have been reports of potential hybrid surgical approaches to management. Studies further show misdiagnosis of penetrating atherosclerotic ulcers in earlier data sets further complicates management. However, it is clear we must progress on the journey towards precision medicine, allowing delivery of optimum care to our patients.
Collapse
Affiliation(s)
- Nehman Meharban
- Barts and the London School of Medicine and Dentistry, 4952Queen Mary University of London, UK
| | - Wahaj Munir
- Barts and the London School of Medicine and Dentistry, 4952Queen Mary University of London, UK
| | | | - Ali Bashir
- Institute of Cardiac and Aortic Disorders, 363954SRM Institutes for Medical Science (SIMS Hospitals), India
| | - Mohamad Bashir
- Vascular Surgery Department, 155510Royal Blackburn Teaching Hospital, UK
| |
Collapse
|
15
|
Stana J, Fernandez Prendes C, Kruszyna L, Passaloglou IT, Ruffino MA, Reyes Valdivia A, Del Castro Madrazo JA, Oikonomou K, Chan HL, Makaloski V, Tsilimparis N. Multicenter Experience With Large Diameter Balloon-Expandable Stent-Grafts for the Treatment of Infrarenal Penetrating Aortic Ulcers. J Endovasc Ther 2021; 28:871-877. [PMID: 34190634 PMCID: PMC8573626 DOI: 10.1177/15266028211028221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose To describe the use of large-diameter balloon-expandable stent-grafts (BeGraft aortic stent-graft, Bentley InnoMed GmbH, Hechingen, Germany) in the treatment of infrarenal penetrating aortic ulcer (iPAU). Materials and Methods Retrospective analysis of patients undergoing endovascular treatment with the BeGraft aortic stent-graft in 8 European centers from January 2017 to October 2020. Demographics, perioperative data, and midterm outcomes were collected. Endpoints of the study were technical feasibility, early mortality, and morbidity. Results A total of 40 patients were included. The mean age was 73.9±7.05 years and 63.2% were male. Indications for treatment included size and morphology (65%), presence of symptoms (29.5%), and contained ruptures (5.5%). Urgent treatment was performed in 5% of cases. Technical success was 97.5%. Median operation time was 58 minutes (19–170 minutes), with 27.5% of patients having additional procedures during the main intervention (1 additional repair with a C-TAG (W.L. Gore & Associates, Inc, Flagstaff, AZ, USA) thoracic endoprosthesis, 5 covered endovascular reconstruction of aortic bifurcation procedures, 3 extensions with proximal cuffs, and 2 percutaneous angioplasties of the common iliac arteries). Percutaneous femoral access was used in 72.5%, while groin cut-down was performed in 27.5%. Repair was successful with only 1 stent in 45% of cases, while 37.5% required 2 stents and nearly 17.5% required 3/4 stent-grafts. The 30-day mortality was 0%, with a 2.5% reintervention rate (1 patient required evacuation of an intra-abdominal hematoma). Median follow-up was 13.9 months (2–39 months), during which no vascular-related reinterventions or deaths were reported. In 4 patients, a type II endoleak was observed. No cases of graft migration, thrombosis, or stent-fracture were observed. Conclusions The treatment of iPAU with the BeGraft aortic stent-graft in a selective patient group is feasible with low rate of perioperative morbidity and mortality. Balloon-expandable stent-grafts offer the option to repair iPAUs with a shorter coverage of the aorta using low-profile sheath, that enables treatment in the presence of calcified access vessels and small diameter aortic bifurcations.
Collapse
Affiliation(s)
- Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| | | | - Lukasz Kruszyna
- Department of General & Vascular Surgery, University of Medical Sciences in Poznan, Poland
| | | | - Maria Antonella Ruffino
- Department of Diagnostic Imaging and Radiotherapy-AOU Città della Salute e della Scienza di Torino, Italy
| | - Andres Reyes Valdivia
- Department of Vascular and Endovascular Surgery, Ramón y Cajal's University Hospital, Madrid, Spain
| | | | - Kyriakos Oikonomou
- Department of Vascular Surgery, University Medical Center Regensburg, Regensburg, Bayern, Germany
| | - Hon Lai Chan
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians University Hospital, Munich, Germany
| |
Collapse
|
16
|
Luo J, Zhao W, Xu J, Zou R, Zhang K, Wan Y, Wan S, Wang R, Zeng Q. Comparative study on clinical efficacy of different methods for the treatment of intramural aortic hematoma. Sci Rep 2021; 11:11752. [PMID: 34083629 PMCID: PMC8175714 DOI: 10.1038/s41598-021-91151-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 05/04/2021] [Indexed: 11/09/2022] Open
Abstract
To explore the difference of curative effect between different treatment modalities, in order to provide reference for the treatment of aortic intramural hematoma (IMH). 168 patients with aortic intramural hematoma diagnosed and treated from January 2010 to July 2020 were selected in the Second Affiliated Hospital of Nanchang University. Among them, 48 patients were diagnosed with Stanford A aortic intramural hematoma and 120 were diagnosed with Stanford B aortic intramural hematoma. According to the therapeutic methods, patients were divided into conservative treatment group and endovascular treatment group (TEVAR). For endovascular treatment group, according to the different timing of surgery, can be divided into acute phase group (onset within 72 h) and non-acute phase group (time of onset > 72 h).The clinical data and follow-up data were collected and analyzed by variance analysis and χ2 test. There were 168 patients diagnosed with aortic intramural hematoma 39 of them were (81.25%) Stanford A aortic intramural hematoma patients with pleural or pericardial effusion. For patient with Stanford A aortic intramural hematoma, endovascular treatment was performed in 15 patients (31.2%), and 33 cases (68.8%) for conservative treatment. The average follow-up (24.9 ± 13.9) was months. There were 120 patients with Stanford type B aortic intramural hematoma (71.4%), 60 patients received endovascular treatment (50%), and 60 patients (50%) received conservative treatment, with an average follow-up of (27.8 ± 14.6) months. For Stanford A type aortic intramural hematoma patients when the maximum aortic diameter ≥ 50 mm or hematoma thickness ≥ 11 mm, with high morbidity and mortality, positive endovascular treatment can reduce complications and death. For patients with Stanford type B aortic intramural hematoma, when the maximum aortic diameter ≥ 40 mm or hematoma thickness ≥ 10 mm, with high morbidity and mortality, positive endovascular treatment can reduce complications and death. Both Stanford type A and B aortic intramural hematoma patients could benefit from the endovascular treatment when the initial maximum aortic diameter is ≥ 50 mm or the hematoma thickness is ≥ 11 mm.
Collapse
Affiliation(s)
- Junfu Luo
- Department of Vascular Surgery, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China
| | - Wenpeng Zhao
- Department of Vascular Surgery, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China
| | - Jiasheng Xu
- Department of Vascular Surgery, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China
| | - Rui Zou
- Department of Emergency, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China
| | - Kaihua Zhang
- Department of General Surgery, The Jiujiang Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China
| | - Yanhua Wan
- Department of General Surgery, The Jiujiang Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China
| | - Shasha Wan
- Department of General Surgery, The Jiujiang Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China
| | - Riwei Wang
- Department of General Surgery, The Jiujiang Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China
| | - Qingfu Zeng
- Department of Vascular Surgery, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006, Jiangxi Province, China.
| |
Collapse
|
17
|
Pandey G, Sharma P. The Management of Patients With Penetrating Aortic Ulcers: A Systematic Review. Vasc Endovascular Surg 2021; 55:730-740. [PMID: 34044670 DOI: 10.1177/15385744211017110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- Gargi Pandey
- Department of Vascular Surgery, 112001Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Paritosh Sharma
- Department of Vascular Surgery, 112001Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| |
Collapse
|
18
|
Jiang X, Liu Y, Chen B, Jiang J, Shi Y, Ma T, Lin C, Guo D, Xu X, Fu W, Dong Z. Clinical features and outcomes after endovascular therapy for penetrating aortic ulcer and intramural hematoma. Vascular 2021; 30:191-198. [PMID: 33906559 DOI: 10.1177/17085381211012573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To identify the differences between clinical features and outcomes after endovascular therapy for penetrating aortic ulcer (PAU) and intramural hematoma (IMH). METHODS From January 2009 to March 2020, patients who underwent endovascular therapy for PAU and IMH were enrolled. Information on patient demographics, presentation, PAU and IMH morphology, laboratory examination, and clinical follow-up information was collected and analyzed. Univariate analysis was performed to identify the differences between IMH and PAU, and Kaplan-Meier was used to calculate the cumulative survival rate and freedom from reintervention. RESULTS A total of 114 patients were enrolled; 80 (70.2%) of them were diagnosed with PAU. Compared with PAU, patients with IMH were younger (p = 0.006), more likely to be admitted emergently (p = 0.001), had longer hospital stay (p = 0.028), and had higher levels of C-reactive protein (p = 0.030). Meanwhile, patients with IMH were more likely to be associated with hypertension (p = 0.020) and pleural effusion (p < 0.001) and less likely to have a history of acute coronary syndrome (p = 0.019) and prior cardiovascular intervention (p = 0.017). The five-year freedom from reintervention and cumulative survival rate were 94.2% (95% confidential interval, 88.9%-99.9%) and 87.8% (95% confidential interval, 79.5%-96.9%) in PAU patients and 89.6% (95% confidential interval, 75.8%-99.9%) and 85.1% (95% confidential interval, 68.0%-99.9%) in IMH patients, respectively. There was no significant difference in freedom from reintervention (p = 0.795) or cumulative survival rate (p = 0.817). CONCLUSIONS IMH appeared to occur in younger patients with hypertension and usually had an acute onset, while PAU was more likely to be found incidentally in older patients with atherosclerosis. Endovascular therapy was effective in both IMH and PAU patients with encouraging outcomes.
Collapse
Affiliation(s)
- Xiaolang Jiang
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yifan Liu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bin Chen
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junhao Jiang
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shi
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changpo Lin
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Xu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
19
|
Modugno P, Centritto EM, Amatuzio M, Testa N, Grimani V, Cilla S, Pierro A, De Filippo CM. Intramural haematoma of the thoracic aorta: A case series. SAGE Open Med Case Rep 2021; 9:2050313X20983207. [PMID: 33456776 PMCID: PMC7797578 DOI: 10.1177/2050313x20983207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022] Open
Abstract
We reported four cases of intramural haematoma of the descending thoracic aorta. Four patients, aged 55-82 years, hypertensive, were transferred from the emergency room of other hospitals due to the appearance of epigastric pain and left thorax pain. All patients underwent computed tomography angiography reporting the presence of intramural haematoma. Three patients underwent a drug therapy to maintain a controlled hypotension. A computed tomography revaluation was performed documenting (1) an increase in the thickness of the intramural haematoma, (2) the appearance of a penetrating ulcer within the haematoma and (3) the appearance of several penetrating lesions throughout the thoracic aorta. Patients required the placement of one or two thoracic aorta endoprosthesis. For the fourth patient, the hyperdense appearance of the intramural haematoma and the presence of pleural effusion suggested an urgent treatment intervention. All patients underwent a placement of cerebrospinal fluid catheter and drainage before treatment. All patients were treated with endovascular intervention with 100% technical success and absence of migration or retrograde type A dissection. There were no complications related to femoral surgical access or access routes. Perioperative mortality was null; no patient had paraplegia. No strokes, transient ischemic attack or perioperative myocardial infarction were observed. The average hospitalization was 5 days. After 3 months, angio-computed tomography reported for all patients a complete reabsorption of the intramural haematoma and a complete exclusion of the penetrating ulcer of the aortic wall present at the time of the intervention. There have been no cases of distant thoracic aortic tears. Endovascular treatment must be considered the preeminent treatment for thoracic aortic haematoma. Best timing to perform the endovascular procedure depends on the patient clinical picture and on stability of hemodynamic parameters.
Collapse
Affiliation(s)
- Pietro Modugno
- Vascular Surgery Unit, Fondazione di ricerca e cura ‘Giovanni Paolo II’, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Enrico Maria Centritto
- Vascular Surgery Unit, Fondazione di ricerca e cura ‘Giovanni Paolo II’, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Mariangela Amatuzio
- Vascular Surgery Unit, Fondazione di ricerca e cura ‘Giovanni Paolo II’, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Nicola Testa
- Cardiac Surgery Unit, Fondazione di ricerca e cura ‘Giovanni Paolo II’, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vittorio Grimani
- Anesthesiology Unit, Fondazione di ricerca e cura ‘Giovanni Paolo II’, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Fondazione di ricerca e cura ‘Giovanni Paolo II’, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Antonio Pierro
- Radiology Unit, Fondazione di ricerca e cura ‘Giovanni Paolo II’, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Carlo Maria De Filippo
- Cardiac Surgery Unit, Fondazione di ricerca e cura ‘Giovanni Paolo II’, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| |
Collapse
|
20
|
Jen JP, Malik A, Lewis G, Holloway B. Non-traumatic thoracic aortic emergencies: imaging diagnosis and management. Br J Hosp Med (Lond) 2020; 81:1-12. [PMID: 33135923 DOI: 10.12968/hmed.2020.0344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The major component of non-traumatic thoracic aortic emergencies is the acute aortic syndromes. These include acute aortic dissection, intramural haematoma and penetrating atherosclerotic ulcer, grouped together because they are indistinguishable clinically and highly fatal. All three entities involve disruption to the tunica intima and media and may be complicated by rupture, end-organ ischaemia or aneurysmal transformation. Early diagnosis is vital to allow timely and appropriate management. Paired unenhanced and electrocardiogram-gated computed tomography angiography of the chest, extending more distally if required, is recommended for diagnosis. Specific computed tomography features of all three entities are reviewed, with a focus on morphological features associated with complications. Those with type A pathology are usually managed with open surgery because this has a high risk of complication. Patients with uncomplicated type B pathology are usually managed with best medical therapy whereas those with complicated type B pathology are usually offered either surgery or thoracic endovascular aortic repair. The limited evidence regarding the use of thoracic endovascular aortic repair in patients with subacute uncomplicated type B pathology is briefly discussed.
Collapse
Affiliation(s)
- Jian Ping Jen
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Akif Malik
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gareth Lewis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Benjamin Holloway
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
21
|
Jiang X, Pan T, Zou L, Chen B, Jiang J, Shi Y, Ma T, Lin C, Guo D, Xu X, Yang J, Shi Z, Zhu T, Dong Z, Fu W. Outcomes of endovascular stent graft repair for penetrating aortic ulcers with or without intramural hematoma. J Vasc Surg 2020; 73:1541-1548. [PMID: 33091512 DOI: 10.1016/j.jvs.2020.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 10/04/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We investigated the outcomes of endovascular repair for penetrating aortic ulcers (PAUs) with and without intramural hematoma (IMH). METHODS Patients with PAUs who had undergone thoracic endovascular aortic repair (TEVAR) or endovascular abdominal aortic repair (EVAR) at our center were enrolled. Patient demographics, presenting symptoms, and anatomic characteristics were collected and analyzed to investigate the TEVAR/EVAR indications, perioperative complications, and mortality. RESULTS We identified 138 patients with PAU. Of the 138 patients, 58 (42.0%) had also had IMH. Compared with the patients without IMH, the patients with IMH had had significantly greater emergency admission rates (P < .01), a larger aortic diameter (P = .03), and a greater incidence of stent-induced new entry development (P = .02). No significant differences were found in mortality or freedom from reintervention between patients with PAUs with and without IMH during follow-up. However, the cumulative survival rates calculated using Kaplan-Meier analysis for patients who had undergone TEVAR/EVAR during their first hospitalization were significantly greater than those who had undergone delayed TEVAR/EVAR during follow-up. CONCLUSIONS TEVAR/EVAR was safe and effective, with encouraging outcomes for patients with PAUs with or without IMH, and can be used more aggressively for symptomatic patients. The presence of PAUs with IMH did not seem to adversely affect long-term mortality. However, but stent-induced new entry was more likely to develop.
Collapse
Affiliation(s)
- Xiaolang Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianyue Pan
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lingwei Zou
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bin Chen
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junhao Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shi
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changpo Lin
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daqiao Guo
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Xu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jue Yang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenyu Shi
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ting Zhu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Weiguo Fu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
22
|
Kaul P, Paniagua R, Petsa A, Singh R. Sequential ruptures of penetrating atherosclerotic ulcers of ascending aorta, aortic arch and descending thoracic aorta. J Cardiothorac Surg 2020; 15:298. [PMID: 33023614 PMCID: PMC7541281 DOI: 10.1186/s13019-020-01311-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022] Open
Abstract
Background Penetrating ulcers of aorta, aortic dissections and intramural hematomas all come under acute aortic syndromes and have important similarities and differences. Case report We report a 67 year old man with rupture of a large penetrating ulcer of the distal ascending aorta with hemopericardium and left hemothorax. He underwent interposition graft replacement of ascending aorta and hemi-arch with a 30 mm Gelweave Vascutek graft but represented 6 months later with development of a penetrating ulcer which ruptured into a huge 14 cm pseudoaneurysm. This was repaired with a 28 mm Vascutek Gelseal graft replacement of arch and interposition graft reconstruction of innominate and left common carotid arteries. 6 weeks later, however, he ruptured his proximal descending aorta and underwent TEVAR satisfactorily. Unfortunately, 2 days later, he developed a pathological fracture of left proximal tibia with metastasis from a primary renal cell carcinoma. He died 3 weeks later from respiratory failure. We shall briefly outline the similarities and differences in presentation and management of penetrating aortic ulcers, aortic dissections and intramural haematomas. We shall discuss, in greater detail, penetrating ulcers of thoracic aorta, their natural history, location, complications and management. Conclusion This case report is unique on account of initial successful surgical redressal following rupture of penetrating ulcer of distal ascending aorta into left pleural and pericardial cavities, normally associated with instant death. The haemodynamic effects of the rupture were staggered due to initial contained rupture into a smaller pseudoaneurysm, followed by a further rupture into a false aneurysmal sac followed eventually by generalised rupture into the pleural and pericardial cavities - a unique way of aortic rupture. Further development of another penetrating ulcer and a small pseudoaneurysm in the distal arch 6 months later which further ruptured into a larger 14 cm false aneurysmal sac, which again did not result in exsanguination, is again extraordinarily rare. Thereafter he underwent emergency thoracic endovascular aortic repair (TEVAR) for a further rupture of descending thoracic aorta. All three ruptures were managed successfully and would usually be associated with near-certain death, only for the patient to succumb eventually to the complications of metastatic renal cell carcinoma.
Collapse
Affiliation(s)
- Pankaj Kaul
- Cardiac Surgeon Leeds General Infirmary, Leeds, LS1 3EX, UK.
| | - Rodolfo Paniagua
- Department of Cardiac Surgery, Leeds General Infirmary, Leeds, LS1 3EX, UK
| | - Afroditi Petsa
- Department of Cardiac Surgery, Leeds General Infirmary, Leeds, LS1 3EX, UK
| | - Raj Singh
- Department of Cardiac Anaesthesia, Leeds General Infirmary, Leeds, LS1 3EX, UK
| |
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW Penetrating aortic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media. With the advances in imaging techniques, the differential diagnosis between PAU and other aortic ulcers remains a challenge. This review aims to summarize the latest insight into PAU, based on clinical context and the newest imaging characteristics, to aid treatment decision-making. RECENT FINDINGS Most PAUs are asymptomatic and do not require urgent invasive treatment. Nevertheless, when PAU leads to an acute aortic syndrome, emergency invasive therapy is recommended. A differential diagnosis with other lesions, such as ulcerated plaques or intimal disruptions within the context of an aortic intramural hematoma, is required as the risk of complications and management differ. Imaging technique plays a pivotal role in the correct diagnosis of aortic ulcers. SUMMARY The differential diagnosis of PAU with other aortic ulcers based on clinical and imaging technique information is mandatory as it may imply different prognosis and management. This diagnosis is particularly important when PAU is the cause of acute aortic syndromes as urgent invasive treatment should be recommended.
Collapse
|
24
|
Yang L, Zhang QY, Wang XZ, Zhao X, Liu XZ, Wang P, Jing QM, Han YL. Long-Term Imaging Evolution and Clinical Prognosis Among Patients With Acute Penetrating Aortic Ulcers: A Retrospective Observational Study. J Am Heart Assoc 2020; 9:e014505. [PMID: 32893719 PMCID: PMC7726995 DOI: 10.1161/jaha.119.014505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Acute penetrating aortic ulcers (PAUs) are reported to dynamically evolve into different clinical outcomes ranging from regression to aortic rupture, but no practice guidelines are available in China. Methods and Results All 109 patients with acute PAUs were monitored clinically. At 30 days follow-up, 31 patients (28.44%) suffered from aortic-related adverse events, a composite of aortic-related mortality, aortic dissection, or an enlarged ulcer. In addition, 7 (6.42%) patients had clinically related adverse events, including all-cause mortality, cerebral stroke, nonfatal myocardial infarction, acute heart failure alone or acute exacerbation of chronic heart failure, acute renal failure, arrhythmia, and bleeding events. In the present study, the intervention criteria for the Chinese PAU population included a PAU diameter of 12.5 mm and depth of 9.5 mm. The multivariate analysis showed that an ulcer diameter >12.5 mm (hazard ratio [HR], 3.846; 95% CI, 1.561-9.476; P=0.003) and an ulcer depth >9.5 mm (HR, 3.359; 95% CI, 1.505-7.494; P=0.003) were each independent predictors of aortic-related events. Conclusions Patients with acute PAUs were at high risk for aortic-related adverse events and clinically related adverse events within 30 days after onset. Patients with an ulcer diameter >12.5 mm or an ulcer depth >9.5 mm have a higher risk for disease progression, and early intervention may be recommended.
Collapse
Affiliation(s)
- Lin Yang
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China.,College of Medicine and Biological Information Engineering Northeastern University Shenyang China
| | - Quan-Yu Zhang
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Xiao-Zeng Wang
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Xin Zhao
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Xuan-Ze Liu
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Ping Wang
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Quan-Min Jing
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Ya-Ling Han
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| |
Collapse
|
25
|
Intravascular Ultrasound-Assisted Endovascular Exclusion of Penetrating Aortic Ulcers. Ann Vasc Surg 2020; 70:467-473. [PMID: 32634558 DOI: 10.1016/j.avsg.2020.06.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Penetrating aortic ulcer (PAU) is an atherosclerotic lesion penetrating the elastic lamina and extending into the media of the aorta. It may evolve into intramural hematoma, focal dissection, pseudoaneurysm, and eventually rupture. The purpose of this study was to evaluate the effectiveness of a totally intravascular ultrasound (IVUS)-assisted endovascular exclusion of PAU. METHODS Thirteen consecutive patients (median age 66 years) underwent IVUS-assisted endovascular exclusion of PAU. The primary end points were fluoroscopy time, radiation dose, and occurrence of type I primary endoleak. Secondary end points were postoperative mortality and morbidity, arterial access complications, postoperative length of stay in the hospital, and occurrence of type II endoleaks. RESULTS The median fluoroscopy time was 4 min (4-5). The median radiation dose was 4.2 mGy (3.9-4.5). A proximal and distal landing zone of at least 2 cm could be obtained in all the patients. No patient presented a type I endoleak. No postoperative mortality, no morbidity, or arterial access complication was observed. The median length of postoperative stay in the hospital was 2 days (2-3). The median length of follow-up was 25 months (9.2-38.7). One late type II endoleak was observed (7.7%), because of reflux from the intercostal arteries, without the need for additional treatment. CONCLUSIONS IVUS-assisted endovascular treatment of PAU allows durable exclusion of PAU with a short fluoroscopy time and no need for injection of contrast media. Further series are needed to confirm the results of this preliminary study.
Collapse
|
26
|
Ge LD, Kang W, Patel P, Patel R, Kizhakekuttu T. Pseudoaneurysm Leading to Aortic Dissection: An Interesting Case Presentation. Cureus 2020; 12:e8545. [PMID: 32670682 PMCID: PMC7357300 DOI: 10.7759/cureus.8545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This is an interesting case of ascending penetrating aortic ulcer (PAU) leading to pseudoaneurysm and eventually type A aortic dissection and peri-aortic hematoma. PAUs are common clinical manifestations, however, uncommonly lead to pseudoaneurysms that cause aortic dissection.
Collapse
|
27
|
Evangelista A, Moral S, Ballesteros E, Castillo-Gandía A. Beyond the term penetrating aortic ulcer: A morphologic descriptor covering a constellation of entities with different prognoses. Prog Cardiovasc Dis 2020; 63:488-495. [PMID: 32497587 DOI: 10.1016/j.pcad.2020.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Penetrating aortic ulcer (AU) is defined as localized disruption of the intimal layer of the aortic wall, resulting in a crater-like lesion outpouching from the vessel contour. AU is a generic term which encompasses a constellation of entities with different etiologies and prognoses and may be a complication of infective, inflammatory, traumatic, iatrogenic, atherosclerotic processes or intramural hematoma. One of the most challenging scenarios of AU for a differential diagnosis, but also for treatment implications, is when they are associated with acute aortic syndrome. Despite advances in the field of aortic disease, lack of consensus defining these lesions and the significant semantic confusion in the medical literature of the acronym PAU (for penetrating aortic ulcer but also for penetrating atherosclerotic ulcer) have given rise to controversy in guidelines and expert consensus, leading to the same treatment being recommended for entities with different etiology and prognosis. Moreover, in the medical literature, most diagnoses were mainly based on imaging techniques which identified AU regardless of clinical symptoms, surrounding imaging findings or dynamic morphologic changes. In this Review, we provide the latest insight into the differential diagnosis between AU, also called penetrating aortic ulcers, based on clinical context and the newest imaging characteristics to aid treatment decision-making.
Collapse
Affiliation(s)
- Arturo Evangelista
- Cardiology Department, Hospital General Universitari Vall d'Hebron, VHIR, CIBER-CV, Barcelona, Spain; Heart Institute, Quirónsalud-Teknon, Barcelona, Spain.
| | - Sergio Moral
- Cardiology Department, Hospital Universitari Doctor Josep Trueta, CIBER-CV, Girona, Spain
| | - Esther Ballesteros
- Radiology Department, Centro de atención primaria Pare Claret, Institut Català de la Salut, Barcelona, Spain
| | | |
Collapse
|
28
|
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.
Collapse
|
29
|
Milligan JM, Dayama A, El Sayed HF, Panneton JM. Current technology for endovascular repair of the aortic arch. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01451-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
30
|
Vaccarino R, Abdulrasak M, Resch T, Edsfeldt A, Sonesson B, Dias NV. Low Iliofemoral Calcium Score May Predict Higher Survival after EVAR and FEVAR. Ann Vasc Surg 2020; 68:283-291. [PMID: 32339675 DOI: 10.1016/j.avsg.2020.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/23/2020] [Accepted: 04/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Abdominal aortic aneurysm is associated with an increased mortality, mostly cardiovascular events. Moreover, aortoiliac calcification is associated with increased mortality in patients with peripheral occlusive disease. The aim of this study is to assess the potential association between iliofemoral calcification, assessed by calcium score, in patients undergoing infrarenal (endovascular aneurysm repair [EVAR]) or fenestrated endovascular aortic repair (FEVAR) and long-term mortality, particularly caused by cardiac events. METHODS All patients with preoperative noncontrast-enhanced computed tomographic scans who underwent infrarenal EVAR and FEVAR of nonruptured abdominal aortic aneurysm between 2004 and 2012 at a single tertiary center were screened for inclusion. Agatston calcium score was measured from the aortic bifurcation to common femoral arteries using a dedicated postprocessing software. The values are presented as median and interquartile range. RESULTS About 404 (62.05%) of 651 patients who underwent EVAR and FEVAR had sufficient imaging quality to be included. There was no difference in survival between included and excluded patients (P = 0.33). Nine patients (2.2%) died within 30 days of the operation, whereas the remaining were followed up for 6.3 (4.7-8.4) years. The iliofemoral calcium score was 8348 (3830-14,179). Estimated overall survival at 5 years was 73 ± 2%. Patients within the lowest quartile of iliofemoral calcium score had significantly higher overall survival (5 years: 79 ± 4% vs. 71 ± 3%; P = 0.01) and cardiac event-free survival (5 years: 95 ± 2% vs. 91 ± 2%; P = 0.033) when compared with the remaining ones. Calcium score was associated with neither univariate regression analysis with survival (odds ratio, 1.016 [0.988-1.045]; P = 0.268) nor cardiac event-free survival (odds ratio, 1.024 [0.986-1.063]; P = 0.222). CONCLUSIONS Low iliofemoral calcium score may be associated with lower incidence of fatal cardiac events and all-cause long-term mortality after EVAR and FEVAR. This may be partially a reflection of aging and cardiovascular comorbidity but needs to be studied further.
Collapse
Affiliation(s)
- Roberta Vaccarino
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
| | - Mohammed Abdulrasak
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Timothy Resch
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Andreas Edsfeldt
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Björn Sonesson
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Nuno V Dias
- Department of Thoracic and Vascular Surgery, Vascular Center, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| |
Collapse
|
31
|
Silverberg D, Bar-Dayan A, Rimon U, Raskin D, Fefer P, Halak M. The Jailed Coiling Technique for the Treatment of Penetrating Ulcers and Saccular Aneurysms of the Aortic Arch. Vasc Endovascular Surg 2020; 54:423-429. [PMID: 32323631 DOI: 10.1177/1538574420921282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the technical success and short-term outcome of patients with penetrating aortic ulcers (PAUs) and saccular aneurysms (SAs) of the aortic arch treated with the jailed coiling technique. METHODS A retrospective review of 9 patients (mean age 70 years, 9 males) treated for PAUs and SAs of the aortic arch between 2018 and 2019 at our institution. Treatment included thoracic endovascular aneurysm repair (TEVAR) with a short (1cm) proximal landing zone, followed by coiling of aneurysm through a jailed extraluminal catheter. RESULTS All 9 patients underwent TEVAR followed by jailed coiling of the lumen of the aneurysms. Debranching of supra-aortic vessels was performed in 4 patients in order to create a proximal landing zone of at least 10 mm. Technical success was achieved in all cases. Coils were placed accurately within the aneurysm lumen in all patients. No distal embolization occurred. One patient expired in the perioperative period from a cardiac event. No patient developed spinal cord ischemia or stroke in the perioperative period. Mean follow-up was 10 months (range 3-18). On follow-up imaging, complete thrombosis of the aneurysm lumen was seen in all patients. None experienced enlargement of ulcer dimensions and none required reintervention. CONCLUSION PAUs and SAs of the aortic arch with a very short landing zone can be treated successfully by jailed coiling of the aneurysm and TEVAR. The procedure is technically feasible and can be performed with minimal morbidity. Long-term durability of the repair needs to be determined.
Collapse
Affiliation(s)
- Daniel Silverberg
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Avner Bar-Dayan
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Uri Rimon
- Division of Interventional Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Daniel Raskin
- Division of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Paul Fefer
- Leviev Cardiovascular Institute, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Moshe Halak
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| |
Collapse
|
32
|
Rokosh RS, Shah N, Safran B, Kim DC, Maldonado TS, Sadek M, Garg K, Jacobowitz G, Rockman C. Natural History, Clinical Significance, and the Role of Vascular Referral in the Management of Penetrating Ulcers of the Abdominal Aorta. Ann Vasc Surg 2020; 67:338-345. [PMID: 32234398 DOI: 10.1016/j.avsg.2020.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/17/2020] [Accepted: 03/17/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Penetrating ulcers of the abdominal aorta (PUAA) are an increasingly common finding on abdominal imaging studies; however, their significance and natural history are not well described. This study's objective was to analyze the demographics, presentation, and outcomes of patients with a radiographic diagnosis of PUAA. MATERIALS AND METHODS Patients at our tertiary referral center were identified for inclusion based on a search for the term "penetrating ulcer" in abdominal computed tomography and magnetic resonance imaging reports between January 2014 and December 2017. Patients' electronic medical records were retrospectively reviewed to determine baseline medical characteristics, imaging indication, and subsequent clinical course, interventions, and outcomes. Aortic diameters and ulcer depths were measured by a single observer on initial and follow-up imaging to assess for association with concomitant aortic pathology, evolving aortic disease, and ulcer progression, defined as increase in depth of ≥ 1 mm. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC), and a threshold P-value of <0.05 was set for significance. RESULTS Ninety-two patients with PUAA were identified; 57 (62%) were male. The mean age at diagnosis was 79.3 years, and comorbidities included hypertension (74%), hyperlipidemia (65%), and malignancy (34%). The most common indication for imaging was chest, back, or abdominal pain (19%). On initial imaging, the mean ulcer depth was 1 cm (range from 0.2 cm to 3.4 cm). Concomitant abdominal aortic dilation ≥ 3 cm was found in 34 (37%) patients. Thirty-six (39%) patients had a vascular surgery consultation immediately after radiographic diagnosis. Follow-up axial imaging was performed on 27 (29%) untreated patients. The overall sample's mean ulcer depth remained essentially unchanged from initial measurement (P = 0.99); however, 14 (52%) patients with follow-up imaging were found to have increased overall aortic diameter. Of the total 92 patients, 9 (10%) underwent an endovascular abdominal aortic intervention during the review period: 2 for symptomatic PUAA and the remainder for progression of concomitant aneurysmal disease. All-cause mortality was 5% during the mean follow-up period of 21.9 months (range 0 to 72.5 months). Of the patients lost to follow-up, 61% did not receive vascular referral after initial diagnosis. CONCLUSIONS PUAA are typically incidental findings identified in elderly, comorbid patients undergoing imaging for an unrelated indication. Although isolated findings of asymptomatic PUAA rarely require surgical intervention, these patients we argue would benefit from vascular surgery referral for long-term follow-up and interval imaging to assess for disease progression and concomitant aortic degeneration, which may necessitate repair. In addition, we observed that most of those patients lost to follow-up did not receive vascular consultation, suggesting that lack of involvement of vascular specialists at the time of diagnosis is a missed opportunity to secure appropriate follow-up and management.
Collapse
Affiliation(s)
- Rae S Rokosh
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Noor Shah
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Brent Safran
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Danny C Kim
- Division of Radiology, NYU Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Caron Rockman
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY.
| |
Collapse
|
33
|
|
34
|
Zoller JK, Gregory SH, Stevens TW, Sanchez LA, Hueneke R. Anesthetic Considerations for Aortic Arch Stenting. J Cardiothorac Vasc Anesth 2019; 33:3163-3175. [DOI: 10.1053/j.jvca.2019.01.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/19/2019] [Accepted: 01/24/2019] [Indexed: 01/16/2023]
|
35
|
Kotsis T, Spyropoulos BG, Asaloumidis N, Christoforou P, Katseni K, Papaconstantinou I. Penetrating Atherosclerotic Ulcers of the Abdominal Aorta: A Case Report and Review of the Literature. Vasc Specialist Int 2019; 35:152-159. [PMID: 31620401 PMCID: PMC6774427 DOI: 10.5758/vsi.2019.35.3.152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 11/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Thomas Kotsis
- Vascular Division, 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Basileios Georgiou Spyropoulos
- 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Asaloumidis
- Vascular Division, 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagitsa Christoforou
- Vascular Division, 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Katseni
- Vascular Division, 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Papaconstantinou
- 2nd Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
36
|
Lomazzi C, Grassi V, Domanin M, De Vincentiis C, Piffaretti G, Trimarchi S. Art of operative techniques: treatment options in arch penetrating aortic ulcer. Ann Cardiothorac Surg 2019; 8:500-508. [PMID: 31463216 DOI: 10.21037/acs.2019.07.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Penetrating aortic ulcer (PAU) of the arch has a focal extent which often represents an adequate anatomic target for thoracic endovascular aortic repair (TEVAR). However, the anatomic constraints represented by the supra-aortic vessels pose either clinical or technical challenges that increase when the PAU develops proximally in the arch. Currently, different types of endografts are commercially available and have been used to treat aortic arch lesions. These include branched/fenestrated endografts for a total endovascular approach, and standard devices that can be used in combination with open/hybrid surgical operations, with the aim to exploit the minimally invasive nature of TEVAR by extending the proximal landing zone when necessary. We describe several current techniques adopted in such settings.
Collapse
Affiliation(s)
- Chiara Lomazzi
- Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Viviana Grassi
- Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Carlo De Vincentiis
- Cardiac Surgery Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Santi Trimarchi
- Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| |
Collapse
|
37
|
Duran ES, Ahmad F, Elshikh M, Masood I, Duran C. Computed Tomography Imaging Findings of Acute Aortic Pathologies. Cureus 2019; 11:e5534. [PMID: 31687308 PMCID: PMC6819069 DOI: 10.7759/cureus.5534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Acute aortic syndromes (AAS) encompass a spectrum of life-threatening conditions characterized by acute aortic pain. AAS include acute aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and aneurysm rupture. The prognosis of AAS is clearly related to prompt diagnosis and appropriate management. The different types of AAS cannot be reliably differentiated solely based on clinical presentation since the clinical features are indistinguishable. Multidetector-row computed tomography (MDCT) with electrocardiographic gating (ECG-gated MDCT) has been used in the acute emergency setting as a powerful clinical tool, which enables rapid and specific diagnosis of aortic pathologies. ECG-gated MDCT significantly reduces motion artifact and avoids potential pitfalls in the diagnosis of AAS. The aim of this review is to evaluate the role of MDCT imaging in the assessment of AAS and to discuss the differentiation of this spectrum of aortic diseases with reference to the key imaging findings.
Collapse
Affiliation(s)
- Elif S Duran
- Radiology, University of Texas Health Rio Grande Valley School of Medicine, Edinburg, USA
| | - Farhan Ahmad
- Radiology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Mohamed Elshikh
- Radiology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Irfan Masood
- Radiology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Cihan Duran
- Radiology, University of Texas Medical Branch at Galveston, Galveston, USA
| |
Collapse
|
38
|
Pereira AH. Intramural hematoma and penetrating atherosclerotic ulcers of the aorta: uncertainties and controversies. J Vasc Bras 2019; 18:e20180119. [PMID: 31360153 PMCID: PMC6636911 DOI: 10.1590/1677-5449.180119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The natural histories of intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU) are highly variable as they may progress to aneurysm formation, rupture, or dissection, or even resolve, in the specific case of IMH. Imaging plays an increasingly important role in clinical and surgical management of IMH and PAU. In contrast to ulcer-like projections, images of intramural blood pools have not been widely reported in CT studies of patients with IMH. Understanding the imaging characteristics and the natural course of each of these entities would help clinicians and surgeons to identify patients at greatest risk for bad prognosis and may improve outcomes. This paper discusses the pathophysiology of these entities, the controversies regarding their natural history, and the prognostic factors that should be identified in CT scans.
Collapse
Affiliation(s)
- Adamastor Humberto Pereira
- Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| |
Collapse
|
39
|
|
40
|
Gabel JA, Tomihama RT, Abou-Zamzam AM, Nekrasov V, Oyoyo UE, Bianchi C, Teruya TH, Kiang SC. Early Surgical Referral for Penetrating Aortic Ulcer Leads to Improved Outcome and Overall Survival. Ann Vasc Surg 2019; 57:29-34. [DOI: 10.1016/j.avsg.2018.12.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/16/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022]
|
41
|
Grande AM, Di Perna D, Valentini A, Arbustini E. Penetrating Atherosclerotic Ulcer of the Ascending Aorta Found Incidentally in a 71-Year-Old Man. Tex Heart Inst J 2019; 46:57-58. [PMID: 30833842 DOI: 10.14503/thij-17-6510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
42
|
Oderich GS, Kärkkäinen JM, Reed NR, Tenorio ER, Sandri GA. Penetrating Aortic Ulcer and Intramural Hematoma. Cardiovasc Intervent Radiol 2018; 42:321-334. [DOI: 10.1007/s00270-018-2114-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/01/2018] [Indexed: 01/10/2023]
|
43
|
Endovascular Repair of a Penetrating Aortic Ulcer with a Custom-made Relay Stent Graft Featuring a Single Celiac Trunk Fenestration and a Superior Mesenteric Artery Scallop. Ann Vasc Surg 2018; 52:314.e1-314.e5. [PMID: 29793012 DOI: 10.1016/j.avsg.2018.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 11/23/2022]
Abstract
We report the case of a 70-year-old man with an asymptomatic, fast-growing, paraceliac penetrating aortic ulcer (PAU). Guidelines recommend endovascular repair if an asymptomatic PAU shows a mean growth rate ≥5 mm per year: this patient's maximum aortic diameter was 47 mm but had increased 10 mm in the previous year. The very short sealing zones required a custom-made stent graft. A custom-made relay stent graft comprises a single celiac trunk fenestration, a superior mesenteric artery (SMA) scallop measured according to SMA ostium size, an uncovered distal stent, and 6-mm tapering was used with technical and clinical success.
Collapse
|
44
|
Lee WMM, Wong OF, Fung HT. Penetrating Atherosclerotic Ulcer - an Increasingly Recognized Entity of the Acute Aortic Syndrome: Case Report and Literature Review. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790901600409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
Collapse
|
45
|
Kaya U, Colak A, Becit N, Ceviz M, Kocak H. Endovascular Stent Graft Repair of Localized Acute Aortic Intramural Hematoma: A Case Report and Literature Review. Eurasian J Med 2017; 49:211-213. [PMID: 29123447 DOI: 10.5152/eurasianjmed.2017.17151] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aortic intramural hematoma (IMH) is a variant of acute aortic syndrome, which can be life-threatening. Ascending aorta IMHs, particularly accompanied by penetrating aortic ulcer (PAU), can cause dissection, rupture, and cardiac tamponade. Therefore, early surgical treatment is recommended for IMHs of the ascending aorta. Herein, we present the case of a 60-year-old male patient who was on warfarin sodium treatment and in whom an IMH localized to the arcus aorta was detected incidentally via computed tomography, with the suspicion of pulmonary embolism, and an endovascular stent graft was inserted into the arcus aorta. This case highlights the importance of following ulcerated aortic plaques and suggests that IMH can be successfully treated with endovascular stent grafting.
Collapse
Affiliation(s)
- Ugur Kaya
- Department of Cardiovascular Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| | - Abdurrahim Colak
- Department of Cardiovascular Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| | - Necip Becit
- Department of Cardiovascular Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| | - Munacettin Ceviz
- Department of Cardiovascular Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| | - Hikmet Kocak
- Department of Cardiovascular Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| |
Collapse
|
46
|
Avenatti E, Iafrati MD, Patel V, Little SH, Pandian NG, Ianchulev SA. Acute Aortic Syndrome - More in the Spectrum. J Cardiothorac Vasc Anesth 2017; 31:1735-1739. [PMID: 28826685 DOI: 10.1053/j.jvca.2017.04.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Eleonora Avenatti
- Department of Cardiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX.
| | - Mark D Iafrati
- Department of Vascular Surgery, Tufts Medical Center, Boston, MA
| | - Visal Patel
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Stephen H Little
- Department of Cardiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Natesa G Pandian
- Department of Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, MA
| | - Stefan A Ianchulev
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| |
Collapse
|
47
|
Abstract
Rarely, penetrating atherosclerotic ulcers can rupture into the wall of the aorta, resulting in acute aortic dissection. This article describes a woman with an incidental diagnosis of type A aortic dissection secondary to a penetrating atherosclerotic ulcer of the ascending aorta. Although surgical repair of the aortic root was recommended, the patient refused treatment and left against medical advice.
Collapse
|
48
|
Diagnostic performance of MDCT angiography in penetrating atherosclerotic aortic ulcer and its complications compared with digital subtraction angiography. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
49
|
Abstract
Saccular aortic aneurysms are eccentrically shaped and are commonly thought to be the consequence of infection of the aorta. However, saccular-type aneurysms can be found independent of any clinical or subclinical infection and can be associated with a penetrating aortic ulcer. Moreover, penetrating aortic ulcers have been described in the thoracic aorta, but there is a paucity of any documentation of this clinical and pathologic entity occurring in the abdominal aorta. The authors describe 2 cases of symptomatic, penetrating atherosclerotic ulcers of the abdominal aorta causing saccular, noninfectious abdominal aortic aneurysms.
Collapse
|
50
|
Tsuji Y, Okita Y, Sugimoto K, Yamashita T, Hino Y, Tanaka H, Taniguchi T, Matsumori M. Multiple Penetrating Atherosclerotic Ulcers of the Aorta: Report of a Case. Vasc Endovascular Surg 2016; 40:495-8. [PMID: 17202098 DOI: 10.1177/1538574406294367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 69-year-old hypertensive man who had 7 pseudoaneurysms caused by penetrating atherosclerotic ulcers underwent 2-staged endovascular grafting in the thoracic and thoracoabdominal aorta and a conventional graft replacement of the abdominal aorta. He had an uneventful postoperative course; follow-up computed tomography demonstrated that all aneurysmal lesions treated by endovascular grafting completely disappeared. He has been free from any aortic events 20 months after the last surgery.
Collapse
Affiliation(s)
- Yoshihiko Tsuji
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
| | | | | | | | | | | | | | | |
Collapse
|