What is the recommended management for a stable 4.0 cm ascending aortic aneurysm with 7.5 mm plaque ulceration at the thoracic arch?

Management of Stable 4.0 cm Ascending Aortic Aneurysm with 7.5 mm Plaque Ulceration at the Thoracic Arch

This patient requires urgent surgical consultation and likely surgical intervention due to the penetrating atherosclerotic ulcer (PAU) at the aortic arch, regardless of the 4.0 cm ascending aortic aneurysm size, as PAU carries a significantly higher risk of rupture (40%) compared to classic aortic dissection. 1

Critical Risk Assessment

The presence of a 7.5 mm plaque ulceration fundamentally changes the management approach:

• Penetrating atherosclerotic ulcers have a 40% rupture risk, which is dramatically higher than type A dissection (7%) or type B dissection (3.6%) 1
• PAU represents ulceration of an atherosclerotic lesion that penetrates through the internal elastic lamina into the media, creating an unstable aortic wall 2
• PAU in the ascending aorta or arch requires emergency surgical treatment once diagnosed, as the natural history is more serious than classic aortic dissection 1, 2

Immediate Management Algorithm

1. Urgent Multidisciplinary Aortic Team Consultation

• Immediate cardiac surgical consultation is mandatory regardless of the aneurysm size, as PAU location and characteristics determine urgency 3, 1
• The combination of ascending aneurysm and arch PAU requires assessment for extent of surgical repair needed 3

2. Medical Stabilization

• Aggressive blood pressure control with beta-blockers and antihypertensive therapy to reduce aortic wall stress 3
• Target systolic blood pressure <120 mmHg to minimize shear stress 3
• Intensive lipid management to LDL-C <55 mg/dL (<1.4 mmol/L) given atherosclerotic etiology 3

3. Imaging Surveillance Protocol (If Surgery Deferred)

• CT or MRI imaging at 6-month intervals for the ascending aneurysm component, as it measures ≥4.0 cm 3, 4
• However, the PAU typically necessitates more frequent monitoring or proceeding directly to surgery 1, 2

Surgical Indications

This patient meets criteria for surgical intervention based on the PAU alone, independent of aneurysm size:

• PAU in the ascending aorta or arch requires surgical management on an emergency basis 2
• The ascending aortic aneurysm at 4.0 cm alone would not meet size criteria for surgery (threshold is ≥5.0-5.5 cm for degenerative aneurysms) 3
• However, PAU with early clinical or radiologic signs of deterioration mandates surgical management 1

Surgical Approach Considerations

• Ascending aortic interposition graft for the PAU and aneurysmal segment 2
• Aortic arch replacement may be necessary depending on PAU location and extent of arch involvement 3
• The procedure requires cardiopulmonary bypass with hypothermic circulatory arrest and brain protection strategies 3
• If arch and descending aorta are involved, elephant trunk procedure may be considered 3

Critical Pitfalls to Avoid

• Do not mistake PAU for simple atherosclerotic plaque: PAU penetrates the vessel wall and has dramatically different rupture risk 1, 2
• Do not apply standard aneurysm size criteria: The 4.0 cm diameter is below typical surgical threshold, but PAU changes risk stratification entirely 1
• Do not delay surgical consultation: PAU patients are older (mean age 76.6 years) with larger aortic diameters and higher rupture risk than dissection patients 1
• Avoid anticoagulation or dual antiplatelet therapy: These increase bleeding risk without benefit in aortic atheroma 3

Medical Management Components

While awaiting surgery or if surgery is declined:

• Single antiplatelet therapy (aspirin) for secondary prevention 3
• Statin therapy with intensive LDL-C lowering target <55 mg/dL 3
• Beta-blocker therapy to reduce aortic wall stress 3
• Strict blood pressure control 3

Monitoring for Deterioration

Signs requiring immediate surgical intervention:

• New or worsening chest or back pain 3
• Hemodynamic instability or hypotension 3
• Radiologic progression of PAU depth or diameter 1
• Development of intramural hematoma or dissection 3
• Evidence of contained rupture 3

The combination of ascending aortic aneurysm with arch PAU represents a high-risk scenario requiring prompt surgical evaluation and likely intervention, as the PAU component carries substantially higher rupture risk than the aneurysm size alone would suggest. 1, 2