How do you manage aortic penetrating ulcers?

Management of Aortic Penetrating Ulcers

All patients with penetrating aortic ulcers (PAU) require immediate medical therapy with aggressive blood pressure and heart rate control, with management strategy then determined by anatomic location (Type A vs Type B) and presence of complications. 1

Initial Medical Management (All Patients)

Medical therapy including pain relief and blood pressure control is mandatory in all patients with PAU regardless of location or severity. 1

Hemodynamic Control Targets

• Target heart rate ≤60 beats per minute using intravenous beta-blockers as first-line agents 2
• Target blood pressure: systolic <120 mmHg and diastolic <80 mmHg 2
• Initiate beta-blockers first and titrate to achieve heart rate control before adding vasodilators 2
• If beta-blockers are contraindicated, use non-dihydropyridine calcium channel blockers as an alternative 2
• After achieving adequate heart rate control, add intravenous ACE inhibitors and/or other vasodilators if systolic BP remains >120 mmHg 2

Critical pitfall: Never initiate vasodilator therapy before achieving heart rate control, as this provokes reflex tachycardia that increases aortic wall stress and risk of rupture 2

Additional Medical Therapy

• Moderate- to high-intensity statin therapy if aortic atherosclerosis is present 2
• Low-dose aspirin (75-162 mg/day) to reduce cardiovascular events 2
• LDL-C reduction by ≥50% from baseline with goal <1.4 mmol/L (<55 mg/dL) 1

Type A PAU (Ascending Aorta)

Surgery is recommended for all Type A PAU. 1 The ascending aorta is rarely affected by PAU, but when it occurs, especially when complicated with intramural hematoma, the risk of rupture is 33%-75% with high mortality from progression to dissection 1

• In highly selected patients with increased operative risk and uncomplicated Type A PAU without high-risk imaging features, a "wait-and-see" strategy may be considered 1

Type B PAU (Descending Thoracic Aorta)

Initial medical therapy under careful surveillance is recommended for all Type B PAU. 1 Over 90% of PAUs occur in the descending thoracic aorta where atherosclerotic changes are most common 2

Uncomplicated Type B PAU

• Repetitive imaging (CMR, CCT, or TOE) is mandatory 1
• Follow-up imaging at 1 month after diagnosis, then every 6 months if imaging findings are stable 1
• Conservative management is appropriate for isolated, asymptomatic, small PAUs with no high-risk features 1, 3
• Approximately 13% of conservatively managed patients demonstrate progression requiring subsequent intervention 4

High-Risk Imaging Features Warranting Intervention

Endovascular treatment (TEVAR) should be considered in uncomplicated Type B PAU with any of the following high-risk features: 1

• Maximum PAU width ≥13-20 mm 1, 2
• Maximum PAU depth ≥10 mm 1, 2
• Significant growth of PAU width or depth >5 mm/year 1, 2
• PAU associated with a saccular aneurysm 1, 2
• PAU with increasing pleural effusion 1, 2
• Aortic diameter >42-50 mm 4, 3
• Concomitant aortic pathology 4

Complicated Type B PAU

Endovascular treatment (TEVAR) is recommended as first-line therapy for complicated Type B PAU. 1

Complications indicating need for intervention include:

• Recurrent or persistent pain despite medical therapy 1, 2
• Hematoma expansion 1, 2
• Periaortic hematoma 1, 2
• Intimal disruption 1
• Signs of impending rupture 5
• Inability to control pain or blood pressure 5

Surgery may be considered in complicated Type B PAU based on anatomy and medical comorbidities when endovascular repair is not feasible. 1

Endovascular vs Surgical Outcomes

The evidence strongly favors endovascular repair when anatomically suitable:

• Early mortality with endovascular treatment is 5%, compared to higher rates with medical management alone and highest with open surgical repair 4
• 30-day mortality after endovascular repair is 0-5% in contemporary series 6, 3
• Approximately 9% of patients require reintervention after initial endovascular surgery 4
• No aortic-related deaths occur in appropriately selected patients managed conservatively 3
• Long-term mortality is similar between conservative and surgical groups when appropriate selection criteria are applied 3

Surveillance Protocol

After TEVAR for PAU

Follow-up imaging is recommended at 1,6, and 12 months post-operatively, then yearly until the fifth post-operative year if no abnormalities are documented. 1

Medically Managed PAU

Follow-up imaging at 1 month after diagnosis, then every 6 months if imaging findings are stable. 1 Patients initially managed conservatively who eventually require surgery do so at a mean interval of approximately 50 months, primarily due to aneurysmal degeneration 3

Diagnostic Imaging

Cardiovascular computed tomography (CCT) represents the technique of choice for diagnosis. 1 The classic appearance is a mushroom-shaped protrusion of the aortic lumen with overhanging edges 2, 5

• TOE and CMR are valid alternatives based on availability and local expertise 1
• 18FDG-PET-CT is a promising technique detecting increased glucose uptake as a marker of metabolic activity 1
• CT has 96% sensitivity for detecting associated intramural hematoma 2

Patient Demographics and Risk Factors

PAU typically affects older males (>65 years), smokers, with multiple comorbidities including systemic hypertension, coronary artery disease, COPD, renal insufficiency, and concurrent abdominal aneurysm 1, 2 Symptoms may manifest after a long asymptomatic phase, and PAU is often diagnosed incidentally during imaging 1, 2

Critical consideration: Symptom onset may indicate PAU expansion involving the tunica adventitia, requiring urgent imaging and therapeutic intervention to prevent aortic rupture 1, 2