What are the guidelines for managing penetrating aortic ulcers?

Management Guidelines for Penetrating Aortic Ulcers

All patients with penetrating aortic ulcers (PAU) require immediate medical therapy with aggressive blood pressure control (systolic <120 mmHg) and heart rate control (≤60 bpm), with subsequent management determined by anatomic location (Type A vs Type B) and presence of complications. 1

Initial Medical Management (Universal for All PAU)

Medical therapy is mandatory for all patients regardless of PAU location or severity. 1

Hemodynamic Control Protocol

• Heart rate control FIRST: Target ≤60 beats per minute using intravenous beta-blockers as first-line agents 2
• Critical pitfall: Never initiate vasodilators before achieving heart rate control, as this provokes reflex tachycardia that increases aortic wall stress and rupture risk 2
• Alternative for beta-blocker contraindications: Use non-dihydropyridine calcium channel blockers 2

Blood Pressure Control Protocol

• Target: Systolic <120 mmHg and diastolic <80 mmHg 2
• After heart rate control achieved: If systolic BP remains >120 mmHg, add intravenous ACE inhibitors and/or other vasodilators 2
• Pain control: Adequate analgesia is essential as part of initial management 1

Diagnostic Imaging

Contrast-enhanced computed tomography (CCT) is the diagnostic technique of choice with 96% sensitivity for detecting associated intramural hematoma. 1, 2

• Alternative imaging modalities: Transoesophageal echocardiography (TOE) or cardiac magnetic resonance (CMR) based on availability and local expertise 1
• Classic imaging appearance: Mushroom-shaped protrusion of the aortic lumen with overhanging edges 2
• Emerging technique: 18FDG-PET-CT can detect increased metabolic activity in PAUs 1

Management by Anatomic Location

Type A PAU (Ascending Aorta)

Surgery is recommended for all Type A PAU. 1

• Exception: 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, 2
• Surgical approach: Ascending aortic interposition graft replacement 3

Type B PAU (Descending Thoracic Aorta)

Initial medical therapy under careful surveillance is recommended for all Type B PAU. 1

Uncomplicated Type B PAU

• Surveillance protocol: Repetitive imaging (CMR, CCT, or TOE) is mandatory 1
• Follow-up schedule: Imaging at 1 month after diagnosis, then every 6 months if findings remain stable 1, 2
• After 2 years of stability: Larger intervals may be considered in low-risk patients 1

Complicated Type B PAU

Endovascular treatment (TEVAR) is recommended as first-line therapy. 1, 2

Complications warranting immediate intervention include: 2

• Recurrent or persistent pain
• Hematoma expansion
• Periaortic hematoma
• Intimal disruption
• Aortic rupture
• Distal ischemia

Alternative: Open surgery may be considered based on anatomy and medical comorbidities 1

Uncomplicated Type B PAU with High-Risk Imaging Features

Endovascular treatment should be considered. 1

High-Risk Imaging Features Requiring Intervention

Any of the following features indicate high risk and warrant consideration for intervention: 1

• Maximum PAU width ≥13-20 mm
• Maximum PAU depth ≥10 mm
• Significant growth of PAU width or depth >5 mm/year
• PAU associated with a saccular aneurysm
• PAU with increasing pleural effusion
• Aortic diameter >42-50 mm at the PAU site 4

Critical warning sign: Symptom onset (especially new or recurrent pain) may indicate PAU expansion involving the tunica adventitia, requiring urgent imaging and intervention to prevent rupture. 1, 2

Long-Term Medical Management

Blood Pressure Control

• Strict long-term blood pressure control is mandatory for all patients with PAU 2
• Continue antihypertensive therapy indefinitely 1

Lipid Management

• LDL-C reduction ≥50% from baseline with goal <1.4 mmol/L (<55 mg/dL) for patients with aortic atherosclerosis 2
• Moderate- to high-intensity statin therapy is recommended if evidence of aortic atherosclerosis exists 2

Antiplatelet Therapy

• Low-dose aspirin (75-162 mg/day) to reduce cardiovascular events 2

Outcomes and Prognosis

Conservative Management

• 13% of patients managed conservatively demonstrate progression requiring subsequent intervention 4
• Overall late mortality exceeds 30-day mortality for PAUs 4
• Small asymptomatic PAUs without high-risk features may be managed conservatively with regular surveillance 1, 4

Endovascular Treatment Outcomes

• Lowest early mortality (5%) compared to medical management or open surgery 4
• Technical success rate: 100% in contemporary series 5, 6
• 30-day mortality: 0-4.5% 5, 6
• Reintervention rate: 9-20.5% at long-term follow-up 4, 6
• 95.5% cumulative survival free from aorta-related death at 100 months 6

Patient Demographics and Risk Factors

Typical PAU patient profile: Older adult (>65 years), male predominance, smoker, with multiple comorbidities including systemic hypertension, coronary artery disease, COPD, renal insufficiency, and concurrent abdominal aneurysm. 2, 4

Risk of rupture when complicated with intramural hematoma: 33-75% 2