What is the treatment for an aortic ulcer rupture?

Treatment of Aortic Ulcer Rupture

Immediate endovascular repair (TEVAR) is the preferred first-line treatment for aortic ulcer rupture, with open surgical repair reserved for cases where endovascular treatment is not feasible or when the rupture involves the ascending aorta. 1

Diagnostic Approach

When aortic ulcer rupture is suspected, prompt diagnosis is essential:

• Imaging modality of choice: CT angiography with non-contrast phase followed by contrast injection to detect contrast leaks indicating rupture 1
• The protocol should include:
  • Assessment of the entire aorta
  • Coverage of iliac and femoral arteries for treatment planning
  • Evaluation for contained vs. free rupture

Imaging Findings Suggestive of Rupture:

• Contrast extravasation
• Periaortic hematoma
• Pleural or peritoneal effusions (particularly if increasing)
• Hemodynamic instability

Treatment Algorithm

1. Initial Stabilization

• Aggressive blood pressure control (systolic target 100-120 mmHg)
• Fluid resuscitation if hypotensive
• Pain management
• Preparation for immediate intervention

2. Treatment Selection Based on Location

Ascending Aorta/Arch Ulcer Rupture:

• Immediate open surgical repair is recommended regardless of size 1
• Higher mortality risk compared to descending aorta ruptures

Descending Thoracic Aorta Ulcer Rupture:

• TEVAR is the preferred treatment 1
  • 30-day mortality: 19% for TEVAR vs. 33% for open repair 1
  • Lower rates of stroke and paraplegia compared to open repair
• Open repair when endovascular approach is not anatomically suitable

Abdominal Aorta Ulcer Rupture:

• Endovascular aortic repair (EVAR) if anatomically suitable
• Open repair for unsuitable anatomy or failed endovascular approach

Specific Considerations for Penetrating Aortic Ulcer (PAU) Rupture

PAU ruptures are particularly dangerous due to their tendency to progress rapidly. Evidence shows:

• Symptomatic PAUs have higher early mortality rates compared to asymptomatic ones 2
• Combined intramural hematoma (IMH) with PAU carries significantly higher risk of adverse outcomes 3
• Complications affect approximately 25% of patients within 30 days and nearly 50% within 1 year of diagnosis 3

Post-Procedure Management

• Intensive care monitoring with frequent assessment of:
  • Vital signs
  • Peripheral pulses
  • Urine output
  • Neurological status (including lower extremity motor strength)
  • Skin assessment for signs of embolization 1

Follow-up Protocol

For patients who survive the acute event:

• First imaging within 1 month post-procedure
• Follow-up imaging at 3,6, and 12 months, then yearly if stable 1
• For medically treated PAU (if intervention was not possible), imaging at 1 month after diagnosis, then every 6 months 1

Pitfalls and Caveats

1. Delayed diagnosis: Contained ruptures may be misdiagnosed as simple back or chest pain
2. Underestimating severity: Contained ruptures can rapidly progress to free rupture with catastrophic consequences
3. Inadequate imaging: Failure to obtain appropriate CT imaging can miss subtle signs of rupture
4. Overreliance on medical management: While medical management is appropriate for uncomplicated PAU, rupture requires immediate intervention
5. Inadequate follow-up: Even after successful treatment, patients require lifelong surveillance due to risk of new aortic events

Mortality Considerations

Aortic ulcer rupture carries significant mortality risk:

• Mortality may reach 54% at 6 hours and 76% at 24 hours after the initial event 1
• Location matters: ruptures closer to the aortic valve carry greater risk of death
• Endovascular repair offers mortality benefit over open repair in most cases (19% vs. 33% 30-day mortality) 1

By following this algorithm and understanding the critical nature of aortic ulcer rupture, clinicians can optimize outcomes in this life-threatening condition.