What is the recommended approach for a patient with an aneurysm of the descending aorta with Penetrating Aortic Ulcer (PAU) and Intramural Hematoma (IMH) who also has Coronary Artery Disease (CAD) with 3-Vessel Disease (3VD) requiring Coronary Artery Bypass Grafting (CABG)?

Staged TEVAR-First Approach for Descending Aortic Aneurysm with PAU/IMH and Concurrent CAD 3VD

Your staged approach of TEVAR first followed by CABG is the correct management strategy for this complex patient, as the descending aortic pathology with PAU and IMH represents a complicated type B acute aortic syndrome requiring urgent intervention, while the coronary disease can be addressed after aortic stabilization. 1, 2

Case Presentation Structure

Patient Demographics and Risk Profile

• Present this as a typical PAU/IMH patient: older adult (usually >65 years), male, with multiple atherosclerotic risk factors including hypertension, coronary artery disease, smoking history, and likely COPD or renal insufficiency 1, 3
• Emphasize that PAU with associated IMH significantly increases risk of treatment failure and adverse outcomes compared to isolated PAU, with rupture risk as high as 33-75% 3, 4
• The combination of aneurysm, PAU, and IMH represents a complicated type B acute aortic syndrome requiring urgent endovascular intervention 1, 2

Clinical Presentation

• Describe presenting symptoms: chest or back pain (typical for PAU/IMH), which may indicate PAU expansion involving the tunica adventitia and impending rupture 1, 3
• Note that persistent or recurrent pain despite medical therapy mandates immediate intervention 1, 2
• Explain the incidental finding of severe CAD 3VD during pre-operative workup 1

Diagnostic Imaging Findings

• Contrast-enhanced CT is the diagnostic technique of choice with 96% sensitivity for detecting IMH 2, 3
• Present high-risk imaging features that justify urgent TEVAR:
  • Maximum PAU width ≥13-20 mm 2, 3
  • Maximum PAU depth ≥10 mm 2, 3
  • PAU associated with saccular aneurysm 2, 3
  • Increasing pleural effusion 2, 3
  • Evidence of periaortic hematoma or intimal disruption 1
• Describe the aneurysm diameter (if ≥55 mm, this alone is an indication for elective TEVAR in descending thoracic aorta) 1
• Include coronary angiography findings showing 3-vessel disease requiring revascularization 1

Rationale for Staged TEVAR-First Approach

Why TEVAR Must Come First

• Complicated type B PAU with IMH warrants TEVAR as first-line therapy, and urgent TEVAR should be performed once hemodynamic stability is achieved rather than delayed elective repair 1, 2
• The presence of PAU with associated IMH in an aneurysmal aorta presents a particularly urgent problem, as this complication may be a precursor to aneurysm rupture 1
• Evidence of disease progression (hematoma expansion, periaortic hematoma, intimal disruption) requires urgent treatment 1
• Prior to AAA repair, routine evaluation with coronary angiography and systematic revascularization in patients with chronic coronary syndromes is not recommended 1 - this principle extends to thoracic aortic pathology, where the aortic emergency takes precedence

Why CABG Can Be Safely Delayed

• The 2024 ESC guidelines explicitly state that routine coronary revascularization before aortic repair is not recommended in stable coronary disease 1
• Medical management of CAD can bridge the patient to CABG after aortic stabilization 1
• The aortic pathology poses immediate life-threatening risk (rupture), while stable CAD 3VD can be managed medically in the short term 2, 3

Timing Between Procedures

• Perform TEVAR urgently once hemodynamic stability is achieved 2
• Allow 4-6 weeks between TEVAR and CABG to ensure:
  • Aortic healing and endograft incorporation 1
  • Resolution of acute inflammatory response 1
  • Dual antiplatelet therapy (DAPT) can be safely held perioperatively for CABG if needed 1
• Schedule first follow-up imaging at 1 month post-TEVAR to assess for endoleaks or complications before proceeding to CABG 1

Initial Medical Management (Pre-TEVAR)

Hemodynamic Control

• Initiate intravenous beta-blockers immediately to achieve target heart rate ≤60 beats per minute before addressing blood pressure, as vasodilators given before heart rate control can provoke reflex tachycardia that increases aortic wall stress 2, 3
• Target blood pressure: systolic <120 mmHg and diastolic <80 mmHg 2, 3
• In patients with contraindications to beta-blockers, use non-dihydropyridine calcium channel blockers 3
• After achieving heart rate control, add intravenous ACE inhibitors and/or other vasodilators if systolic BP remains >120 mmHg 3

Pain Management

• Provide adequate analgesia as pain control is essential - uncontrolled pain may indicate disease progression 1, 2
• Pain relief is a Class I recommendation in all patients with IMH 1

Coronary Medical Management

• Initiate optimal medical therapy for CAD: high-intensity statin, aspirin, beta-blocker (already indicated for aortic disease) 1, 2
• Consider short-acting nitrates for angina symptoms if blood pressure allows 1

TEVAR Technical Considerations

Pre-Procedural Planning

• Obtain contrast-enhanced CT with ≤3 mm slice thickness of entire aorta from supra-aortic branches to femoral arteries 5
• Measure proximal and distal landing zones carefully 5
• Minimum landing zone length of 20 mm is required both proximally and distally for safe deployment and durable fixation 5
• Assess relationship to left subclavian artery and intercostal arteries 5

Device Sizing

• Oversize the stent-graft by 10-15% relative to the reference aortic diameter measured at the proximal and distal landing zones 5
• For PAU/IMH, avoid excessive oversizing to minimize risk of stent-graft induced new entry (SINE) 5
• Ensure proximal landing zone does not exceed 40 mm in diameter for standard TEVAR devices 5

Left Subclavian Artery Management

• If planned LSA coverage is necessary, revascularize the LSA before TEVAR to reduce the risk of spinal cord ischemia and stroke 1
• Perform left carotid-subclavian bypass if LSA coverage required 6

Intraoperative Considerations

• Reduce systolic blood pressure to <80 mmHg during stent-graft deployment to prevent downstream displacement 5
• Consider intraoperative IVUS or TOE for real-time diameter verification 5
• Maintain strict hemodynamic control throughout procedure 1, 2

Common Pitfalls and How to Avoid Them

Pitfall 1: Delaying TEVAR to Perform CABG First

• This is dangerous - the PAU/IMH with aneurysm poses immediate rupture risk, while stable CAD can be managed medically 1, 2
• Performing CABG first exposes the patient to hemodynamic stress and anticoagulation that could precipitate aortic rupture 1, 2

Pitfall 2: Underestimating Risk of PAU with Associated IMH

• PAU with IMH has significantly worse outcomes than isolated PAU, with 5-year freedom from reintervention only 57.7% after TEVAR versus 97.1% for isolated PAU 7, 4
• Associated IMH increases risk for TEVAR treatment failure (need for reintervention, rupture, or aortic-related death) 4
• This mandates more aggressive surveillance and lower threshold for reintervention 4

Pitfall 3: Inadequate Blood Pressure Control

• Vasodilators should NOT be initiated before heart rate control, as reflex tachycardia increases aortic wall stress 3
• Uncontrolled hypertension is a known risk factor for aortic rupture and dissection 3
• Maintain strict BP control indefinitely post-TEVAR 2, 3

Pitfall 4: Insufficient Landing Zone Length

• Landing zones <20 mm increase risk of type I endoleak and device migration 5
• Carefully measure and plan coverage zones, accepting LSA coverage with revascularization if necessary for adequate seal 1, 5

Pitfall 5: Inadequate Follow-Up After TEVAR

• Patients with PAU/IMH require more intensive surveillance than standard TEVAR patients 4
• Perform imaging at 1 month post-TEVAR before proceeding to CABG 1
• After CABG, continue surveillance at 3,6, and 12 months, then yearly 1, 2

Post-TEVAR Management Before CABG

Immediate Post-Operative Period

• Continue strict blood pressure control (systolic <120 mmHg) 2, 3
• Maintain heart rate control with beta-blockers 2, 3
• Monitor for complications: endoleak, stroke, spinal cord ischemia, access site complications 1

One-Month Follow-Up Imaging

• Perform CT imaging at 1 month post-TEVAR to assess success of intervention and identify any endoleaks before proceeding to CABG 1
• Type I endoleak requires reintervention before CABG 1
• Type III endoleak requires reintervention before CABG 1
• Type II endoleaks can be observed if aneurysm sac is stable 1

Medical Optimization for CABG

• Continue optimal CAD medical therapy 1
• Initiate moderate- to high-intensity statin therapy with LDL-C goal <55 mg/dL (<1.4 mmol/L) 2, 3
• Continue aspirin 75-162 mg/day 2, 3
• Ensure adequate renal function and optimize comorbidities 1

Long-Term Surveillance Strategy

Imaging Schedule

• After TEVAR: imaging at 1,3,6, and 12 months, then yearly if stable 1, 2
• Use CT or CMR for surveillance 1
• Monitor for late aneurysm formation, dissection progression, or endoleak development 2

Medical Management

• Continue strict blood pressure control indefinitely with target systolic <120 mmHg 2, 3
• Maintain heart rate control with beta-blockers 2, 3
• Continue high-intensity statin therapy 2, 3
• Continue aspirin for cardiovascular risk reduction 2, 3

Reintervention Thresholds

• Type I or III endoleak requires reintervention 1
• Aneurysm sac expansion >5 mm requires evaluation for reintervention 3
• New symptoms (pain, signs of rupture) require urgent imaging and intervention 1, 2
• Evidence of disease progression (new IMH, PAU expansion) requires aggressive management 2, 3

Key Points for Case Discussion

Emphasize the Evidence Base

• TEVAR is recommended over open repair for descending thoracic aortic aneurysms when anatomy is suitable (Class I, Level B recommendation) 1
• Complicated type B IMH warrants TEVAR (Class I, Level C recommendation) 1
• Routine coronary revascularization before aortic repair is not recommended in stable CAD (Class III, Level C recommendation) 1

Highlight the Complexity

• This case represents the intersection of three high-risk pathologies: aneurysm, PAU, and IMH 2, 3
• The presence of IMH with PAU significantly worsens prognosis and increases treatment failure rates 7, 4
• Staged approach balances immediate life-threatening aortic risk against need for coronary revascularization 1, 2

Discuss Alternative Approaches and Why They Were Rejected

• Simultaneous TEVAR + CABG: One case report describes this approach 4, but it exposes the patient to prolonged anesthesia, hemodynamic instability, and anticoagulation during acute aortic syndrome - not recommended
• CABG first, then TEVAR: This delays treatment of life-threatening aortic pathology and exposes unstable aorta to hemodynamic stress of cardiac surgery - contraindicated 1, 2
• Medical management alone: Complicated type B PAU/IMH with aneurysm has high rupture risk and requires intervention 1, 2, 3

Address Expected Outcomes

• 30-day mortality for TEVAR in PAU is approximately 5.4% 4
• Stroke risk is 5.4%, spinal cord ischemia risk is 5.4% 4
• 5-year freedom from TEVAR treatment failure is only 57.7% for PAU with IMH versus 97.1% for isolated PAU 4
• 10-year survival after TEVAR for PAU is 47.9%, with age and urgent presentation as predictors of late mortality 7
• Despite higher early morbidity risk, TEVAR provides similar late survival to open repair with reduced early complications 7