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 be managed with initial medical therapy under careful surveillance, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. The management plan should include:
- Medical therapy with pain relief and blood pressure control, as recommended by the 2024 ESC guidelines 1
- Regular vascular surgery follow-up every 6 months with serial imaging to monitor the penetrating ulcer in the descending aorta and to reassess the status of the previously identified AAA
- Strict blood pressure control with a target of <130/80 mmHg using appropriate antihypertensive medications such as an ACE inhibitor (e.g., lisinopril 10-40 mg daily) or ARB, along with a statin (e.g., atorvastatin 40-80 mg daily) for atherosclerosis management, as supported by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1
- Smoking cessation is essential if the patient smokes
- Evaluation of the dilated upper pole calices in the left kidney by a nephrologist to determine the cause and appropriate management
- Education of the patient about symptoms requiring urgent medical attention, including severe chest or back pain, which could indicate progression of aortic disease The 2024 ESC guidelines recommend that in cases of type B PAU, initial medical therapy under careful surveillance is recommended, and in uncomplicated type B PAU, repetitive imaging (CMR, CCT, or TOE) is recommended 1. Additionally, the guidelines suggest that in uncomplicated type B PAU with high-risk imaging features, endovascular treatment should be considered 1. However, the patient's specific condition and imaging features should be taken into account when making treatment decisions.
From the Research
Management of Abdominal Aortic Aneurysm (AAA) with Penetrating Ulcer
- The patient's condition involves a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, which is a life-threatening condition requiring prompt diagnosis and treatment 2, 3, 4.
- The presence of moderate atherosclerosis and a history of AAA increases the risk of aortic rupture or other complications 5, 6.
- Imaging modalities such as CT angiography, magnetic resonance imaging, and transesophageal echocardiography can be used to diagnose and monitor the condition 3, 5.
- Surgical treatment, including open surgery or endovascular stent grafting, may be necessary to prevent aortic catastrophe such as intramural hematoma, dissection, or rupture 5, 6.
- The patient's symptoms, such as pain or signs of impending rupture, should be closely monitored, and medical therapy may be used to control blood pressure and prevent further complications 3, 6.
- The dilated upper pole calices of the left kidney may indicate renal impairment, which should be evaluated and managed accordingly.
Treatment Options
- Endovascular treatment is a viable option for patients with acute diseases of the descending thoracic aorta and may be considered for patients with ruptured abdominal aortic aneurysms 2.
- Open surgery with a knitted Dacron graft may be performed to repair the aortic aneurysm and prevent further complications 5.
- Medical therapy, including blood pressure control and pain management, may be used to manage symptoms and prevent further complications 3, 6.
Monitoring and Follow-up
- Regular follow-up imaging studies, such as CT angiography or magnetic resonance imaging, should be performed to monitor the patient's condition and detect any signs of complications or disease progression 3, 5.
- The patient's symptoms and medical history should be closely monitored, and any changes or concerns should be promptly evaluated and addressed 3, 6.