What is the management of aortic arch ulcers?

Management of Aortic Arch Ulcers

In patients with aortic arch penetrating atherosclerotic ulcers (PAUs), endovascular treatment should be considered for those with high-risk imaging features, while initial medical therapy under careful surveillance is recommended for uncomplicated cases. 1

Classification and Initial Assessment

Aortic arch ulcers are part of the acute aortic syndrome spectrum and require careful evaluation to determine appropriate management. Key factors to assess include:

• Location (type A vs. type B)
• Presence of symptoms (pain, malperfusion)
• High-risk imaging features:
  • PAU diameter >20 mm
  • PAU depth >10 mm
  • Aortic diameter >42 mm
  • Associated aneurysmal change
  • Pleural effusion
  • Evidence of progression/instability

Management Algorithm

1. Type A PAU (Involving Ascending Aorta/Arch)

• Surgery is recommended 1
• Open surgical replacement is the standard approach for symptomatic patients at low or intermediate operative risk 1
• For asymptomatic patients with arch diameter ≥5.5 cm and low operative risk, open surgical replacement is reasonable 1

2. Type B PAU (Descending Aorta)

• Initial medical therapy under careful surveillance is recommended 1
• Medical therapy includes:
  • Pain relief
  • Blood pressure control (target SBP <120 mmHg and heart rate ≤60 bpm) 1
  • Intravenous beta-blockers (e.g., labetalol) as first-line agents 1
  • If necessary, IV vasodilators (dihydropyridine calcium blockers or nitrates) 1

3. Complicated Type B PAU

• Endovascular treatment (TEVAR) is recommended 1
• Complications include:
  • Rupture
  • Malperfusion
  • Refractory pain
  • Rapid expansion
  • Hemodynamic instability

4. Uncomplicated Type B PAU with High-Risk Features

• Endovascular treatment should be considered 1
• High-risk features include:
  • PAU diameter >20 mm
  • PAU depth >10 mm
  • Aortic diameter >42 mm
  • Morphological changes on serial imaging 2

Imaging Surveillance Protocol

For medically treated PAU:

• Follow-up imaging at 1 month after diagnosis
• Then every 6 months if imaging findings are stable
• After 2 years of imaging stability, larger intervals should be considered in low-risk patients 1

Special Considerations

Endovascular Approach Challenges

• Arch and access vessel complications occur in approximately 27% of TEVAR cases for PAU 3
• Common complications include:
  • Access issues requiring iliac conduits (8.1%)
  • Retrograde type A dissection (5.4%)
  • Transient ischemic attacks (5.4%)
  • Access site complications requiring repair (5.4%)

Long-term Outcomes

• Approximately 13% of patients initially managed conservatively will demonstrate progression requiring intervention 2
• Endovascular treatment has the lowest early mortality (5%) compared to open surgical management 2
• Overall long-term mortality is around 30% at 4 years, with most deaths not being aortic-related in conservatively managed patients 4

Pitfalls and Caveats

1. Misdiagnosis: PAUs can be misdiagnosed as classic aortic dissection but have different management implications and prognosis 5

2. Underestimation of risk: PAUs have a higher risk of rupture (40%) compared to type A (7%) or type B (3.6%) aortic dissections 5

3. Delayed intervention: Failure to recognize high-risk features may lead to rupture; careful surveillance is essential

4. Access complications: Thorough pre-procedural planning is necessary to avoid access and arch-related complications during TEVAR 3

5. Overtreatment: Small, asymptomatic PAUs without high-risk features can often be managed conservatively with good outcomes 4, 6

By following this management approach, clinicians can appropriately treat aortic arch ulcers while minimizing both the risks of rupture and unnecessary interventions.