What is the treatment for a patient with diffuse atherosclerotic disease, an ascending thoracic aorta measuring 3.4 cm, a saccular aneurysm, and a penetrating ulcer of the aortic isthmus?

Management of Penetrating Atherosclerotic Ulcer with Saccular Aneurysm at the Aortic Isthmus

Thoracic endovascular aortic repair (TEVAR) is the recommended treatment for a penetrating atherosclerotic ulcer (PAU) with saccular aneurysm at the aortic isthmus measuring 4.2 cm, especially with evidence of progression. 1

Understanding the Condition

• PAU is defined as ulceration of atherosclerotic plaque that penetrates the internal elastic lamina into the aortic media, which can lead to intramural hematoma, saccular aneurysm formation, or aortic rupture 1, 2
• PAUs most commonly affect the descending thoracic aorta (61.2% of cases) and are less common in the aortic arch (6.8%) 3
• The presence of a saccular component (2.6 cm in this case) with a penetrating ulcer significantly increases the risk of progression and rupture 1, 3

Indications for Intervention

• The total aortic diameter of 4.2 cm with a saccular component and evidence of progression (growth from 2.5 cm to 2.6 cm) warrants intervention 1, 3
• Key factors indicating need for intervention include:
  • Saccular aneurysm formation (present in this case) 3
  • Location at the aortic isthmus (higher risk area) 4
  • Evidence of progression on serial imaging 1, 3
  • Presence of diffuse atherosclerotic disease (increases risk) 5

Treatment Algorithm

1. Initial Medical Management

• Begin aggressive blood pressure control with intravenous beta blockers targeting systolic blood pressure <120 mmHg and heart rate ≤60 beats per minute 6
• If beta blockers are contraindicated, use non-dihydropyridine calcium channel blockers 6
• Add vasodilators only after heart rate control is established to avoid reflex tachycardia 6

2. Definitive Treatment

• TEVAR (Thoracic Endovascular Aortic Repair) is the preferred intervention for PAU with saccular aneurysm at the aortic isthmus 1, 3
• TEVAR offers lower perioperative morbidity and mortality compared to open surgical repair, especially in patients with diffuse atherosclerotic disease 1
• Open surgical repair should be considered if:
  • TEVAR is anatomically unsuitable 7
  • The patient has connective tissue disorders that would contraindicate endovascular repair 1

3. Post-Intervention Surveillance

• CT or MRI imaging at 1 month, 6 months, and then yearly after intervention 1
• Lifelong blood pressure control with target <130/80 mmHg 5
• High-intensity statin therapy for underlying atherosclerotic disease 5

Special Considerations

• PAUs with saccular aneurysms have a higher risk of rupture (4.1% in one series) compared to isolated PAUs 3
• Symptomatic PAU disease is more likely to require repair than asymptomatic disease (36.2% vs 7.8%) 3
• Even asymptomatic PAUs require close monitoring as 16.7% show radiographic progression 3

Common Pitfalls and Caveats

• Do not delay intervention for a PAU with saccular aneurysm at the aortic isthmus, as this location is particularly prone to rupture 4
• Avoid confusing PAU with other acute aortic syndromes (classic aortic dissection or isolated intramural hematoma), as management strategies differ 1, 2
• Never initiate vasodilator therapy before heart rate control is achieved, as this can increase aortic wall stress 6
• Regular imaging surveillance is essential even after successful intervention, as new PAUs may develop in other aortic segments 1