Penetrating atherosclerotic ulcer

Endovascular Repair of Penetrating Thoracic Aortic Ulcers Using Tubular Stent Grafts Versus Stent Grafts With a Proximal Scallop

PURPOSE

In penetrating aortic ulcers (PAUs), limited data support tubular thoracic endovascular aortic repair (TEVAR) as a viable treatment option. For treatment of more proximal PAUs, hybrid approaches and-more recently-scalloped TEVAR (scTEVAR) have been advocated. Outcomes of scTEVAR specifically for PAUs have not yet been reported. This study reports long-term outcomes for tubular and scTEVAR in PAUs and compares the safety profile in both cohorts regarding the significantly more proximal landing zone (LZ) for scTEVAR.

MATERIALS AND METHODS

This single-center retrospective cohort study includes all nonacute patients treated for complicated PAU with scTEVAR and tubular TEVAR. Patient and PAU characteristics as well as procedural success, complication and reintervention rates, and all-cause and aortic mortality were analyzed.

RESULTS

Of 212 TEVAR procedures reviewed, 21 patients with tubular TEVAR and 19 patients with scTEVAR were included. Patient and PAU characteristics were similar, and LZ was significantly more proximal in the scTEVAR cohort (p=0.0001), with similar number and types of supra-aortic revascularization procedures. Clinical success was reached in all 40 patients (100%), and reintervention rate was 2/21 (9.5%) and 1/19 (5.3%), respectively. Over the mean follow-up of 63 (TEVAR) and 53 (scTEVAR) months, clinical success was stable in all patients with one (abdominal) aortic-related mortality in the scTEVAR cohort.

CONCLUSION

Treatment of complicated PAUs with TEVAR as well as scTEVAR provides excellent and similar clinical success, stability of clinical success, and aortic survival with acceptable complication and reintervention rates. Scalloped TEVAR safely lengthens the proximal sealing zone to address more proximal pathologies.

CLINICAL IMPACT

Treatment of asymptomatic complicated penetrating aortic ulcers (PAUs) with thoracic endovascular aortic repair (TEVAR) provides excellent clinical success and acceptable complication and reintervention rates. More patients become amenable to endovascular treatment by including scalloped TEVAR (scTEVAR) as a means to safely lengthen the proximal sealing zone to address more proximal pathologies.

Thoracic aortic pseudoaneurysm: Inside its pathophysiology

OBJECTIVES

Our aim was to investigate pathophysiology of pseudoaneurysm of the thoracic aorta, an acute or chronic pathology, respectively, secondary to blunt thoracic trauma and aortitis, or complicating a deep penetrating aortic ulcer, intraparietal hematoma, aortic aneurysm, and even aortic graft, often with atherosclerosis as a common background.

METHODS

Given the relative rarity of this disease, an "inductive" retrospective method made it possible to retrieve clinical, radiological, and histopathological elements, which were mutually compared and validated through a "deductive" process of reinterpretation.

RESULTS

We have identified three main structural constituents of this disease: a cavity, a single blood entry port, communicating with the aortic lumen, and a pseudocapsule. It is often caused by a chronic degenerative pathology of the intima and medial layers of the aorta, typically involving elastic fibers and smooth muscle cells, with possible intermediate stages of deep aortic ulcer or intraparietal hematoma. Otherwise, the acute onset may be secondary to acute aortitis or aortic injury.

CONCLUSIONS

Today, thanks to the current angiographic tools represented by 3-D high resolution multidetector CT and MRI angiography, the diagnosis of thoracic aortic pseudoaneurysm is easier, as well as its surgical indications.

Successful Interventional Endovascular Management of Ruptured Penetrating Aortic Ulcer with Associated Enormous Right Pleural False Aneurysm

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.

Endovascular treatment of penetrating atherosclerotic ulcers of the arch and thoracic aorta: In-hospital and 5-year outcomes

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.

MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal

Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient’s management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replicable, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.