What is the management approach for a penetrating atherosclerotic ulcer?

From the Guidelines

The management of a penetrating atherosclerotic ulcer (PAU) should involve a combination of medical therapy and potential surgical intervention based on the patient's clinical presentation and risk factors, with a focus on aggressive blood pressure control, pain management, and stabilization of the atherosclerotic plaque, as recommended by the 2024 ESC guidelines 1. The initial management includes aggressive blood pressure control targeting systolic blood pressure between 100-120 mmHg using beta-blockers such as metoprolol (25-100 mg twice daily) or labetalol (100-300 mg twice daily), along with other antihypertensives as needed, as well as pain management with opioid analgesics to reduce sympathetic stimulation 1. Patients should receive antiplatelet therapy with aspirin (81-325 mg daily) and statin therapy (such as atorvastatin 40-80 mg daily) to stabilize the atherosclerotic plaque, as suggested by the guidelines 1. For uncomplicated PAUs, conservative management with close imaging surveillance using CT angiography at 1,3,6, and 12 months is appropriate, according to the recommendations 1. However, surgical intervention with endovascular repair is indicated for PAUs with complications such as rapid expansion (>5 mm in 6 months), diameter >55 mm, persistent pain despite medical therapy, rupture, or signs of impending rupture, as outlined in the guidelines 1. The high-risk imaging features of PAUs, including maximum PAU width ≥13–20 mm, maximum PAU depth ≥10 mm, significant growth of PAU width or depth >5 mm/year, PAU associated with a saccular aneurysm, and PAU with an increasing pleural effusion, should be taken into consideration when deciding on the management approach, as described in the guidelines 1. Open surgical repair may be necessary for patients unsuitable for endovascular approaches, as recommended by the guidelines 1. This management approach is justified by the pathophysiology of PAUs, which involve ulceration through the intima into the media, potentially leading to intramural hematoma, pseudoaneurysm formation, or aortic rupture if left untreated, as explained in the guidelines 1.

Some key points to consider in the management of PAUs include:

• Aggressive blood pressure control and pain management to reduce the risk of complications
• Stabilization of the atherosclerotic plaque with antiplatelet and statin therapy
• Close imaging surveillance for uncomplicated PAUs
• Surgical intervention with endovascular repair for complicated PAUs or those with high-risk imaging features
• Consideration of open surgical repair for patients unsuitable for endovascular approaches
• The importance of taking into account the patient's clinical presentation and risk factors when deciding on the management approach, as recommended by the guidelines 1.

From the Research

Management Approach for Penetrating Atherosclerotic Ulcer

The management approach for penetrating atherosclerotic ulcer (PAU) can vary depending on the severity and symptoms of the condition. Some key points to consider include:

• PAU is a serious condition that can lead to bleeding complications and rupture in up to 40% of patients 2
• There is no generally accepted therapeutic regimen for PAU, but it is increasingly considered to be treated more aggressively, preferably surgically 2
• Endovascular stent-graft repair may be an attractive, less invasive alternative in selected patients with PAU, as it can reduce wall stress and provide stabilization of the diseased aortic segment 2, 3
• Surgical treatment should be performed for patients with PAU to prevent an aortic catastrophe caused by rapid development of the lesion 4
• The decision to treat PAU surgically or with endovascular repair depends on various factors, including the location and size of the ulcer, the presence of symptoms, and the patient's overall health status 5, 6

Treatment Options

Some treatment options for PAU include:

• Endovascular stent-graft repair: a minimally invasive procedure that involves placing a stent-graft in the aorta to cover the ulcer and prevent further bleeding or rupture 2, 3
• Surgical repair: a more invasive procedure that involves surgically removing the affected portion of the aorta and replacing it with a graft 4
• Medical management: a conservative approach that involves managing the patient's blood pressure and monitoring the ulcer for any changes or complications 4

Imaging Techniques

Imaging techniques play a crucial role in the diagnosis and management of PAU. Some common imaging techniques used include:

• Computed tomography (CT) scans: to visualize the aorta and detect any ulcers or other abnormalities 3, 6
• Transesophageal echocardiography (TEE): to confirm the diagnosis and evaluate the extent of the ulcer 3
• CT aortogram: to visualize the aorta and detect any bleeding or other complications 3