CT Surveillance for Penetrating Aortic Ulcer with Saccular Aneurysmal Degeneration
For a penetrating aortic ulcer (PAU) of the infrarenal aorta with saccular aneurysmal degeneration, you should obtain CT imaging at 1 month after diagnosis, then every 6 months thereafter until imaging findings stabilize, at which point you may consider extending intervals in low-risk patients after 2 years of stability. 1
Initial Surveillance Protocol
Obtain baseline CT imaging at 1 month after initial diagnosis to establish the trajectory of disease progression, as PAUs with saccular degeneration represent high-risk features requiring close monitoring 1
Follow with CT imaging every 6 months for medically managed PAU, as recommended by the 2024 ESC Guidelines, which specifically address PAU surveillance intervals 1
Rationale for Aggressive Surveillance
The combination of PAU with saccular aneurysmal degeneration places this patient in a particularly high-risk category that warrants more frequent monitoring than isolated PAU:
Saccular aneurysms have substantially higher rupture risk than fusiform aneurysms and must be repaired at smaller diameters 2
PAUs with associated saccular aneurysms required repair in 52% of cases (26 of 50 repairs) in one series, making this the most common indication for intervention 3
Symptomatic PAU disease progressed radiographically in 42.9% of cases versus only 16.7% for asymptomatic disease, and symptomatic patients required repair 36.2% of the time versus 7.8% for asymptomatic patients 3
Progressive aortic enlargement with saccular and fusiform aneurysm formation is the natural history of PAU when follow-up is sufficient 4
Modifying Surveillance Intervals
After 2 years of documented imaging stability in low-risk patients, you may consider extending surveillance intervals to annually 1
Low-risk features include:
- Asymptomatic presentation 3
- No growth on serial imaging 1
- Absence of intraluminal thrombus 2
- Stable or decreasing saccular component 4
If any progression is documented at any surveillance timepoint, return to CT imaging every 3-6 months depending on the rate of growth observed 1
Critical Pitfalls to Avoid
Do not use ultrasound as the primary surveillance modality for PAU with saccular degeneration—CT provides superior visualization of ulcer depth, saccular morphology, and aortic wall characteristics that are critical for risk stratification 3, 4
Do not extend surveillance intervals beyond 6 months in the first 2 years, even if the patient is asymptomatic, as 23% of PAUs demonstrated radiographic progression at mean follow-up of only 8.4 months 3
Do not ignore new or recurrent symptoms between scheduled imaging, as symptomatic PAU disease has a 36.2% repair rate and warrants immediate repeat imaging 3
Avoid fluoroquinolones in this patient unless absolutely necessary, as they may accelerate aneurysm growth 5, 6
Indications for Immediate Intervention
Consider urgent endovascular repair (EVAR) if surveillance imaging demonstrates:
- Rapid expansion (≥5 mm in 6 months or ≥10 mm per year) 5
- Saccular component reaching intervention threshold (typically when the saccular portion approaches 20-25 mm in diameter, though no absolute threshold exists) 7, 2
- Development of contained rupture or intramural hematoma 3, 7
- Recurrent or persistent symptoms despite medical management 3
The technical success rate for endovascular repair of infrarenal PAU is high (100% in one series), with 30-day survival of 94.7%, making it the preferred approach when intervention is indicated 7