What is the recommended management for a patient with penetrating ulcers of the ascending aorta, aortic arch and descending thoracic aorta, an ascending aortic aneurysm measuring 4.3 × 4.8 cm, a 26.6 × 25.6 mm fusiform infrarenal abdominal aortic dilatation, >50% stenoses of the superior mesenteric artery (SMA), inferior mesenteric artery (IMA) and renal arteries, carotid and subclavian atherosclerotic plaques, exophytic renal lesions, airway secretions, and mild emphysematous changes?

Immediate Multidisciplinary Referral and Aggressive Medical Management Required

This patient requires urgent vascular surgery consultation within 24-48 hours due to multiple penetrating aortic ulcers (PAUs) in the ascending aorta, arch, and descending thoracic aorta, combined with an ascending aortic aneurysm measuring 4.8 cm and critical mesenteric/renal arterial stenoses. 1, 2

Immediate Actions (Within 24 Hours)

Urgent Vascular Surgery Consultation

• Emergency surgical evaluation is mandatory for PAUs involving the ascending aorta (Type A), as these carry a 33-75% rupture risk and 57% mortality within 30 days if managed medically alone. 2, 3
• The presence of multiple PAUs in the ascending aorta represents an extremely high-risk scenario requiring immediate surgical consideration, as Type A PAUs should be treated similarly to Type A aortic dissections. 1, 2

Aggressive Hemodynamic Control (Start Immediately)

• Target heart rate ≤60 beats per minute using intravenous beta-blockers as first-line therapy (unless contraindicated, in which case use non-dihydropyridine calcium channel blockers). 1, 2
• Target systolic blood pressure <120 mmHg and diastolic <80 mmHg. 1, 2, 4
• Critical pitfall: Never initiate vasodilators before achieving heart rate control, as reflex tachycardia will increase aortic wall stress and rupture risk. 1, 2
• After heart rate control, add intravenous ACE inhibitors and/or other vasodilators if systolic BP remains >120 mmHg. 1

Additional Urgent Consultations

• Interventional radiology/vascular surgery for mesenteric revascularization planning due to >50% stenoses of both SMA and IMA, which place the patient at risk for acute mesenteric ischemia. 5
• Nephrology consultation for >50% left renal artery stenosis and bilateral perinephric stranding. 5
• Pulmonology consultation for the 10.6 mm endobronchial lesion requiring bronchoscopy to rule out malignancy versus inspissated secretions. 5

Surgical Decision-Making Algorithm

Ascending Aorta Management

• The ascending aortic aneurysm at 4.8 cm with multiple PAUs requires surgical repair. While isolated ascending aortic aneurysms are typically repaired at ≥55 mm, the presence of PAUs changes the risk-benefit calculation dramatically. 5, 1, 2
• The combination of PAUs with an aneurysm measuring 4.8 cm (which has grown 0.4 cm since prior study) represents a precursor to rupture. 2
• Surgical approach: Open repair with ascending aortic replacement is recommended over endovascular options for Type A PAUs. 1, 2, 3

Descending Thoracic Aorta Management

• The PAUs in the descending thoracic aorta (Type B) should initially be managed medically with close surveillance, unless complications develop. 1, 2
• Indications for TEVAR in Type B PAUs include: recurrent/persistent pain despite medical therapy, hematoma expansion on serial imaging, periaortic hematoma, intimal disruption, or high-risk imaging features (PAU width ≥13-20 mm, depth ≥10 mm, growth >5 mm/year, associated saccular aneurysm, or increasing pleural effusion). 1, 2
• The largest PAU in the descending aorta (image 75) requires measurement of width and depth to determine if it meets high-risk criteria. 1, 2

Infrarenal Abdominal Aortic Management

• The 26.6 mm fusiform infrarenal AAA does not meet criteria for repair (threshold ≥55 mm in men, ≥50 mm in women). 5
• Continue surveillance with duplex ultrasound every 6-12 months. 5

Mesenteric and Renal Revascularization Strategy

Superior Mesenteric Artery (>50% Stenosis)

• Percutaneous endovascular treatment is indicated for symptomatic chronic mesenteric ischemia. 5
• Assess for symptoms: postprandial abdominal pain, weight loss, food fear. 5
• If the patient is asymptomatic but requires aortic surgery, consider prophylactic SMA revascularization during the same procedure. 5

Inferior Mesenteric Artery (Significant Ostial Stenosis)

• IMA stenosis is less critical if SMA is patent, but combined SMA/IMA disease increases ischemia risk. 5
• Address during aortic surgery if technically feasible. 5

Renal Artery Stenoses

• The >50% left renal artery stenosis with bilateral perinephric stranding suggests possible renal ischemia. 5
• Evaluate for renovascular hypertension and declining renal function. 5
• Consider endovascular intervention if hypertension is refractory or renal function is deteriorating. 5

Surveillance Imaging Protocol

Short-Term Surveillance (First 6 Months)

• CT angiography of chest/abdomen/pelvis at 1 month, then at 3 and 6 months to monitor PAU evolution, aortic diameter changes, and assess for complications. 1, 2
• Each scan should specifically measure: PAU width and depth, aortic diameter at all segments, presence of periaortic hematoma, pleural effusion, and branch vessel involvement. 5, 1

Long-Term Surveillance (After 6 Months)

• If stable, continue CT angiography every 6 months for the first 2 years, then annually. 5
• Critical pitfall: MRI may be preferred over CT for long-term surveillance to minimize cumulative radiation exposure, especially in younger patients. 5

Long-Term Medical Management (Lifelong)

Blood Pressure Control

• Maintain systolic BP <120 mmHg and diastolic <80 mmHg indefinitely. 1, 2, 4
• Beta-blockers should remain first-line therapy. 4
• Add ARBs as adjunct therapy to achieve target BP. 4

Lipid Management

• Initiate moderate-to-high intensity statin therapy with goal LDL-C <55 mg/dL (<1.4 mmol/L) and ≥50% reduction from baseline. 1, 4
• This is critical given extensive aortic atherosclerosis with calcific and non-calcific plaques throughout. 1, 4

Antiplatelet Therapy

• Low-dose aspirin 75-162 mg daily to reduce cardiovascular events. 1

Lifestyle Modifications

• Absolute avoidance of strenuous lifting, pushing, or straining requiring Valsalva maneuver. 4
• Mandatory smoking cessation (if applicable) given emphysematous changes. 4
• Aerobic exercise is permitted with well-controlled heart rate and blood pressure. 4

Additional Diagnostic Workup

Renal Lesion Evaluation

• The 7.3 × 10 × 9 mm exophytic isodense lesion in the right kidney lower pole requires further characterization. 5
• MRI abdomen with and without IV contrast (renal protocol) is recommended to differentiate between cyst and solid lesion, as the absence of pre-contrast images limits current assessment. 5
• Correlate with any prior ultrasound imaging. 5

Gastric Mucosal Prominence

• The prominent gastric mucosal folds in fundus and body require clinical correlation. 5
• Consider upper endoscopy if patient has symptoms of gastritis, dyspepsia, or unexplained anemia. 5

Endobronchial Lesions

• The 10.6 mm hyperdensity at the right main bronchus origin requires bronchoscopy to rule out malignancy, even though secretions are suspected. 5
• Follow-up chest CT in 4-6 weeks if bronchoscopy is delayed or non-diagnostic. 5

Carotid/Vertebral Artery Assessment

• The calcific plaque proximal to the left vertebral artery origin with caliber attenuation requires further evaluation. 5
• Carotid duplex ultrasound or CTA neck is recommended to assess for hemodynamically significant stenosis. 5

Prognosis and Natural History

• Without intervention, Type A PAUs have a 57% 30-day mortality rate. 3
• Type B PAUs have a more favorable natural history with medical management, with 20 documented cases of uncomplicated long-term outcomes without surgery. 3
• However, PAUs can progress to saccular pseudoaneurysm (seen in 5 of 17 ulcers in one series), fusiform aneurysm, or cause progressive aortic enlargement over time. 6
• The risk of aortic dissection and rupture exists but is less common than progressive aneurysmal degeneration. 6, 3

5, 1, 2, 4, 6, 3, 7, 8, 9