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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Secondary aorto-duodenal fistula successfully treated with a novel surgical method: A case report

INTRODUCTION

Secondary aorto-duodenal fistula (sADF) is a complication of abdominal aorta artificial blood vessel replacement that often leads to death. However, an optimal operative method has not yet been established. We describe a patient who underwent artificial blood vessel reimplantation and duodenectomy after endovascular aneurysmal repair (EVAR) with positive outcomes.

PRESENTATION OF CASE

An 84-year-old man underwent artificial blood vessel replacement in 2015. In September 2016, he visited our emergency department and was diagnosed with sADF based on computed tomography. Urgent EVAR was performed, followed by duodenal segmental resection on the next day without opening the syringeal part to minimize the pollution of the operative field. Artificial blood vessel reimplantation and omental flap transposition were performed. As of 2020, about 3 years after surgery, there has been no relapse of the infection.

DISCUSSION

Using our novel operative method, we can minimize exposure of the artificial blood vessel and surrounding tissue to intestinal juice and pus. We believe that this reduces the risk of postoperative artificial blood vessel reinfection.

CONCLUSION

Controlling bleeding by EVAR and resection of the duodenum and artificial blood vessels as a group without opening the syringeal part can contribute to positive long-term results as this method minimizes the pollution of the duodenectomy surgical field.

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

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

Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

OBJECTIVES

To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs).

METHODS

This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type.

RESULTS

Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups).

CONCLUSIONS

Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients.

Aorto-enteric Fistula 15 Years After Uncomplicated Endovascular Aortic Repair with Unforeseen Onset of Endocarditis

Introduction

Aorto-enteric fistula after endovascular aortic repair is an exceedingly rare but serious condition.

Report

A rare case of a fistula between the excluded aortic sac and the transverse colon 15 years after endovascular aortic repair is described. Onset was endocarditis without gastrointestinal haemorrhage, migration, endoleak, or aortic sac dilatation. The patient was successfully treated by fistula excision, debridement and broad spectrum antibiotic treatment without endograft explantation.

Discussion

Aorto-enteric fistula can emerge after endovascular repair with an unforeseen onset such as endocarditis, which in this case probably occurred as metastatic sepsis from endograft infection.

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Uneventful endovascular aneurysm repair can generate an aorto-enteric fistula to a successful excluded and stable aneurysm sac.

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This case underlines the need for awareness of unusual symptoms that could represent potential late EVAR related complications.

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A conservative approach without graft removal seems feasible in this case with severe comorbidity.

Acute Infectious Pseudoaneurysm of the Descending Thoracic Aorta and Review of Infectious Aortitis

Thoracic aortic wall disruptions may occur secondary to trauma, surgical interventions, infection, or autoimmune or idiopathic inflammatory disorders. Such vessel wall disruption can lead to aortic dissections, aneurysm development, or more commonly, pseudoaneurysm (PSA) formation. Although aortic wall infections as an antecedent to mycotic aneurysms have been recognized since the 17th century, there has been a temporal evolution in the development of this disease. Prior to the antibiotic era they were commonly associated with endocarditis or syphilis. More recently, however, they are associated with infection of a damaged atherosclerotic area of the aorta and secondary hematogenous or contiguous seeding. We report the first case of the rapid development of a pseudoaneurysm in the descending thoracic aorta attributable to an infection of a contiguous esophageal duplication cyst by a diagnostic esophageal ultrasound (EUS) fine-needle aspiration. A literature review of mycotic thoracic aortic aneurysms and pseudoaneurysms is also presented.

Diagnosis and management of aortic mycotic aneurysms

We reviewed all papers most recently reported in the literature (January-December 2008) with regard to infected arterial aneurysms (IAAs) affecting the aorta. Most of the recently reported knowledge is limited to case reports and small series of aortic mycotic aneurysms. Most patients are elderly men and have comorbidities at presentation. Aneurysms were most commonly associated to Salmonella and Staphylococcus. However, several cases of aortic IAAs caused by atypical pathogens were also reported, likely due to an increase in immunosuppressive illnesses, increased life expectancy, improved diagnostic methods, and increasing medical awareness. Open surgical therapy of IAAs remains the gold standard. Some have reported successful outcomes with endovascular methodologies for patients medically compromised or for particular challenging clinical or anatomical scenarios. However, at this time, conclusive evidence is lacking and it should be in general considered a bridge to open repair. The latter should be planned at the earliest possible, when medically permissible.