What is the management for a patient with a history of abdominal aortic aneurysm (AAA) presenting with moderate atherosclerosis, a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, and dilated upper pole calices of the left kidney?

From the Guidelines

The patient with a history of abdominal aortic aneurysm (AAA) presenting with moderate atherosclerosis, a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, and dilated upper pole calices of the left kidney should undergo close monitoring with regular vascular imaging every 6-12 months, and medical management should include antiplatelet therapy, blood pressure control, and high-intensity statin therapy. The management of this patient should prioritize the prevention of further vascular events and the monitoring of the penetrating ulcer and AAA. According to the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1, a comprehensive approach that addresses the entirety of arterial circulation is recommended. The patient should undergo regular vascular imaging, such as CT angiogram or MRI, to assess for progression of the penetrating ulcer and to monitor the status of the previously identified AAA. The medical management should include:

• Antiplatelet therapy, such as aspirin 81mg daily, to reduce the risk of further vascular events 1
• Blood pressure control targeting <130/80 mmHg with medications such as an ACE inhibitor or ARB, to reduce the risk of cardiovascular events 1
• High-intensity statin therapy, such as atorvastatin 40-80mg or rosuvastatin 20-40mg daily, to reduce the risk of cardiovascular events 1 The patient should also be advised to quit smoking if applicable, maintain regular exercise, and follow a heart-healthy diet, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. Additionally, the dilated upper pole calices in the left kidney suggest possible obstruction that should be evaluated by a urologist with additional imaging such as a renal ultrasound. The penetrating aortic ulcer measuring represents a focal weakening of the aortic wall that could potentially progress to pseudoaneurysm or rupture if left unmonitored, and the management should be guided by the recommendations for the management of penetrating atherosclerotic ulcer, which suggest that in uncomplicated type B PAU with high-risk imaging features, endovascular treatment should be considered 1.

From the Research

Management of Abdominal Aortic Aneurysm (AAA) with Penetrating Atherosclerotic Ulcer

The management of a patient with a history of abdominal aortic aneurysm (AAA) presenting with moderate atherosclerosis, a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, and dilated upper pole calices of the left kidney involves several considerations.

• The presence of a penetrating atherosclerotic ulcer (PAU) is a significant factor, as it can lead to acute aortic syndrome, and its management depends on the clinical context and imaging characteristics 2.
• The patient's history of AAA is also crucial, as it increases the risk of rupture and other complications. The management of AAA typically involves medical management for asymptomatic patients with aneurysms less than 5 cm in diameter, with a focus on modifiable risk factors such as smoking cessation and blood pressure control 3.
• The presence of moderate atherosclerosis and a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta may require closer monitoring and potentially more aggressive management, as these factors can increase the risk of complications such as rupture or dissection 4, 5.
• The dilated upper pole calices of the left kidney may indicate renal impairment or other underlying conditions that need to be addressed in the management plan.

Treatment Options

The treatment options for this patient may include:

• Medical management, focusing on modifiable risk factors such as smoking cessation and blood pressure control 3, 6.
• Endovascular repair, such as thoracic endovascular aortic repair (TEVAR) or endovascular aneurysm repair (EVAR), which may be suitable for patients with anatomy not amenable to standard endovascular repair or those who are not suitable candidates for open surgical repair 4, 6.
• Open surgical repair, which may be indicated for patients with more complex anatomy or those who require more extensive repair 3, 6.
• Close monitoring and surveillance, including regular imaging studies to assess the size and growth of the aneurysm, as well as the progression of the penetrating ulcer 4, 5.