Penetrating atherosclerotic ulcers of the thoracic aorta

Penetrating ulcer of the thoracic aorta is defined as an atherosclerotic lesion of the descending thoracic aorta with ulceration that penetrates the internal elastic lamina, allowing hematoma formation in the media. There is controversy whether this lesion differs from classic acute type III aortic dissection, based on its location, radiographic findings, natural history, and recommended therapeutic approach. Of 47 patients with a diagnosis of aortic dissection seen at our hospital during a 2-year period, five patients had clinical and radiographic findings of penetrating ulcer. Each of the five patients had characteristic computerized tomographic (CT) findings and two patients had angiographic confirmation. In all patients CT showed subintimal hemorrhage, aortic wall enhancement, absence of a double lumen, and contrast extravasation through the ulceration. In both patients who underwent angiography, ulceration, subintimal hematoma, and absence of a false lumen were demonstrated. The clinical presentation in four patients simulated acute aortic dissection or expanding thoracic aneurysm. The other patient, who was normotensive, did not have symptoms referable to the thoracic aorta but was studied because of an abnormal chest x-ray film. None of these five patients required surgical intervention. All five patients were alive and free of symptoms at 6 months, 8 months, 14 months (two patients), and 30 months after the original diagnosis. Follow-up CT scans in four patients showed resolution of subintimal hematoma and some dilatation of the lumen but no progression to rupture or aneurysm. Other authors stress the importance of differentiating symptomatic penetrating atherosclerotic ulcers from acute type III aortic dissection because of the higher incidence of rupture of penetrating ulcers and therefore recommend early surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis and treatment of thoracic aortic intramural hematoma

Purpose: This report reviews our recent experience with nine patients who had intramural hematoma of the thoracic aorta.Methods: This was a retrospective study of all patients who had intramural hematoma at our institution from 1989 to 1994. Patients who had identifiable intimal flap, tear, or penetrating aortic ulcer were excluded from the study.Results: Among these nine elderly patients (mean age, 76 years), the most common presentation was chest or back pain. Intramural hematoma was diagnosed by a variety of high-resolution imaging techniques. The descending thoracic aorta alone was involved in seven patients, whereas the ascending aorta was affected in the other two patients. One patient had evidence of an aneurysm (5.0 cm diameter) in the region of the hematoma. All patients were initially managed nonsurgically with blood pressure control. Both patients who had ascending aortic involvement had progression of aortic hematoma, which resulted in death in one case and in successful surgery in the other. Six of the seven patients who had descending aortic involvement alone were successfully managed without aortic surgery. The patient who had intramural hematoma and associated aortic aneurysm, however, had severe, recurrent pain and underwent successful aortic replacement. Another patient had recurrent pain associated with hypertension, but was successfully managed nonsurgically with antihypertensive therapy. All eight survivors are doing well at a median follow-up of 19 months.Conclusions: Intramural hematoma appears to be a distinct entity, although overlap with aortic dissection or penetrating aortic ulcer exists. Aggressive control of blood pressure with intensive care unit monitoring has been our initial management. Patients who have involvement of the descending thoracic aorta alone can frequently be managed without surgery in the absence of coexisting aneurysmal dilatation or disease progression. Our experience suggests that a more aggressive approach with early surgery is warranted in patients who have ascending aortic involvement or those who have coexisting aneurysm and intramural hematoma. (J Vasc Surg 1996;24;1022-9.)     

Will Stent-Graft Repair Emerge as Treatment of Choice for Acute Type B Dissection?

Endovascular stent grafts are now accepted globally and approved by the US Food and Drug Administration as an alternative to open surgical repair for patients with descending thoracic aortic aneurysm. However, as opposed to the abdominal aorta, application of this technology to manage thoracic aortic disease is not limited to degenerative aneurysms. In fact, international registries and surveys estimate that only 60% of the thoracic cases managed currently with stent-graft placement are aneurysms. The remainder of this experience includes acute dissection, chronic dissection, traumatic aortic injury, penetrating ulcer, intramural hematoma, aortic fistula, anastomotic pseudoaneurysm, and an embolizing lesion. In this regard, it is important to keep in mind that the present devices used in these nonaneurysmal applications are not designed to address the unique anatomical and pathological features that these lesions present. Consequently, in the future, it is possible that we will see stent-graft designs that focus specifically on the challenges of some of the nonaneurysmal thoracic aortic pathologies.     

Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch

OBJECTIVE: The clinical behavior of penetrating atherosclerotic ulcers of the aorta is controversial. We reviewed our experience with this entity over a 25-year interval. METHODS: Cases were identified using the Department of Radiology database searching for the diagnoses of aortic dissection, intramural hematoma, or penetrating ulcer between 1977 and 2002. Available imaging studies were reviewed by a vascular radiologist to confirm the diagnosis of penetrating ulcer and perform serial measurements. RESULTS: One hundred five patients with penetrating atherosclerotic ulcers of the descending thoracic aorta or arch with (n = 85) or without (n = 20) associated intramural hematoma were confirmed. Two patients with ulcers in the ascending aorta were excluded. There were 73 men and 32 women with a mean age of 72 +/- 9 years. Comorbidities included hypertension in 97 (92%), tobacco use in 81 (77%), and coronary artery disease in 48 (46%). Of nonoperated patients with follow-up studies, the mean thickness of the intramural hematoma decreased at 1 month in 89% and completely resolved at 1 year in 85%. There were 3 deaths (4%) within 30 days among 76 patients treated medically and 6 deaths (21%) among 29 patients treated surgically (P <.05). Failure of medical therapy defined as surgery or death was predicted by rupture at presentation (odds ratio = 20.6) and era of treatment (before 1990, odds ratio 9.9) but not aortic diameter, ulcer size, or extent of hematoma. CONCLUSION: Although careful follow-up is necessary, many penetrating atherosclerotic ulcers of the thoracic aorta can be managed nonoperatively in the acute setting.     

急性Stanford B型主动脉壁间血肿的治疗

目的 探讨急性Stanford B型主动脉壁间血肿的治疗方法和预后.方法 总结2001年1月至2008年3月收治的Stanford B型主动脉壁间血肿29例的临床资料.依据以下标准将患者分为三组:(1)有主动脉硬化性穿透性溃疡;(2)血压不易控制;(3)持续胸背部不适.符合上述任何一项的患者入选为腔内治疗组(13例),其余患者归入药物治疗组(16例).腔内治疗组采用降主动脉覆膜支架置入术;药物治疗组只接受降压、止痛等内科保守治疗.结果 本组29例患者均获随访,随访时间6～89个月,平均(19±16)个月,药物治疗组16例患者3例病情进展为夹层予支架治疗,2例突发主动脉破裂而死亡,疾病恶化率为31.25%,死亡率为12.5%;腔内支架治疗组13例患者随访期间未见夹层复发、支架移位及其他并发症.总共置入覆膜支架16个.结论 急性Stanford B型主动脉壁间血肿疾病恶化率高,腔内覆膜支架置入术是积极有效的治疗方法.     

Rupture of the descending thoracic aortic aneurysm in the lung: report of a case

A 65-year-old man underwent a prosthetic graft replacement for a rupture of the saccular descending thoracic aneurysm in the lung. Chest computed tomography (CT) performed on the day of admission was suggestive of a thrombosed localized aortic dissection. However, sagittal plane CT performed on the following day indicated the rupture of a penetrating atherosclerotic ulcer. The operation was performed approximately 36h after the onset of the symptom since diagnosis was difficult due to the following reasons. First, the size of the saccular aortic aneurysm was not sufficiently large, i.e., it was 4.5 cm diameter and 3.0 cm in length. Second, the aneurysm was completely filled with thrombus: therefore, it could not be enhanced on CT scanning. Third, since the aneurysm was present on the side of the greater curvature of the descending aorta, the protrusion of the aneurysm was very indistinct. Fourth, the amount of bleeding was not significant because the rupture was extremely small, approximately 2 mm in width. Fifth, only an interlobar hematoma was observed due to the tight adhesion of the lung with the aorta.     

Intramural hematoma of the thoracic aorta in octogenarians: is non operation justified?

OBJECTIVE: The prognostic factors and treatment options for thoracic aortic intramural hematoma are controversial. The purpose of this study was to determine the most suitable treatment of this condition in very elderly patients. METHODS: In a review of the world literature, eight octogenarians with thoracic aortic intramural hematoma were found; to these the three cases reported here must be added. The descending thoracic aorta was involved in eight cases and the ascending/arch in three. RESULTS: In spite of patients' poor general conditions, the medical treatment group showed survival rates of 85.7% (descending) and 66.6% (ascending/arch), respectively. CONCLUSION: Extensive atherosclerotic changes of the aortic wall in the elderly, combined with control of hypertension, may probably prevent thoracic aortic intramural hematoma from progressing to dissection, with a favourable outcome. An earlier and more accurate preoperative diagnosis by modern diagnostic techniques, including spiral computed tomography (CT), as were performed in our own patients, will allow optimal treatment and increased patient survival.     

Penetrating ulcer of the thoracic aorta: What is it? How do we recognize it? How do we manage it?

Background: Although classic type A and B aortic dissections have been well described, less is known about the natural history of penetrating atherosclerotic ulcers of the thoracic aorta. This study differentiates penetrating ulcer from aortic dissection, determines the clinical features and natural history of these ulcers, and establishes appropriate correlates regarding optimal treatment. Methods: A retrospective review of patient records and imaging studies was conducted with 198 patients with initial diagnoses of aortic dissection (86 type A, 112 type B) at our institution from 1985 to 1997. Results: Of the 198 patients, 15 (7.6%) were found to have a penetrating aortic ulcer on re-review of computed tomographic scans, magnetic resonance images, angiograms, echocardiograms, intraoperative findings, or pathology reports. Two ulcers (13.3%) were located in the ascending aorta; the other 13 (86.7%) were in the descending aorta. In comparison with those with type A or B aortic dissection, patients with penetrating ulcer were older (mean age 76.6 years, p = 0.018); had larger aortic diameters (mean diameter 6.5 cm); had ulcers primarily in the descending aorta (13 of 15 patients, 86.7%); and more often had ulcers associated with a prior diagnosed or managed AAA (6 of 15 patients, 40.0%; p = 0.0001). Risk for aortic rupture was higher among patients with penetrating ulcers (40.0%) than patients with type A (7.0%) or type B (3.6%) aortic dissection (p = 0.0001). Conclusions: Accurate recognition and differentiation of penetrating ulcers from classic aortic dissection at initial presentation is critical for optimal treatment of these patients. For penetrating ulcer, the prognosis may be more serious than with classic type A or B aortic dissection. Surgical management is advocated for penetrating ulcers in the ascending aorta and for penetrating ulcers in the descending aorta that exhibit early clinical or radiologic signs of deterioration. (J Vasc Surg 1998;27:1006-16.)     

Aortopulmonary fistula caused by penetrating atherosclerotic ulcer and intramural hematoma

A 75-year-old woman presented with chronic cough and hemoptysis. Chest computed tomography (CT) and aortography revealed a small, contrast-filled outpouching in the wall of the descending aorta, which was thought to be the source of bleeding. At thoracotomy, there were firm adhesions between the descending aorta and the left S6. The aorta was clamped and the adhesions were removed revealing a defect in the aortic wall with thrombus. The defect was sutured. A penetrating atherosclerotic ulcer and intramural hematoma were diagnosed based on the radiological and operative findings.     

Spontaneous rupture of the thoracic aorta

A case was presented of spontaneous rupture of the descending aorta through an atheromatous plaque without aneurysm or aortic dissection at the site of rupture. A 65 year-old-female with past history of well controlled hypertension developed chest pain along with hypovolemic shock. The patient underwent emergency CT examination which revealed left pleural effusion. There were no signs of a false lumen or aneurysm. At surgery a 5 mm of perforation in the mid portion of descending aorta was found to be surrounded by a large hematoma. The perforation was successfully plicated with predget-supported sutures. Spontaneous rupture of thoracic aorta is a rare, life-threatening condition for which emergency diagnostic and therapeutic measures are indicated. Only 7 cases could be found in the review of the literature, and this is the first reported case in this country.     

Thoracic aortic imaging without angiography.

Imaging of the thoracic aorta without recourse to angiography has great theoretic appeal. We have used computerized tomography (CT) in the initial evaluation of 297 patients with suspected mediastinal disease. Nineteen of this group had important findings related to the thoracic aorta: aortic dissection (six), descending thoracic aortic aneurysm (nine), suspected aortic trauma (three), and suspected false aneurysm at a coarctation repair (one). In all cases, the aorta and related pathology were readily demonstrated by CT, aided by the intravenous infusion of contrast material. In 13 of 15 cases, aortic dissection and aortic aneurysm could be accurately diagnosed. In two instances of ascending aortic dissection, it was not possible to distinguish the false lumen from mural thrombus in an atherosclerotic aneurysm.     

Evolution toward dissection of an intramural hematoma of the ascending aorta

Intramural hematoma of the aorta is a condition increasingly observed in clinical practice. Uncertainty exists whether such lesions represent a different pathology or simply the precursors of classic dissecting aneurysm. The patient was a 76-year-old woman with intramural hematoma of the ascending aorta. Clinical course, progression of the lesion to type A aortic dissection, and surgical treatment are described. Although natural history of intramural hematoma of the ascending aorta is not clearly elucidated, the case presented confirms that the evolution toward intimal flap formation is possible and that we cannot foresee the stabilization of these lesions. We stress that intramural hematoma of the ascending aorta has to be managed as an aortic type A dissection and that aggressive treatment is advisable.     

主动脉腔内支架隔绝术治疗降主动脉瘤

目的探讨主动脉腔内支架隔绝术治疗降主动脉瘤的适应证和疗效。方法2005年3月-2008年10月,对21例典型B型（Stanford分型）主动脉夹层、5例假性动脉瘤、2例主动脉壁内血肿合并主动脉壁溃疡,在局麻（26例）或全麻（2例）下行主动脉腔内支架隔绝术。采用Medtronic Talent支架10例,Medtronic Valiant支架12例,微创直管型支架6例。结果28例手术均获成功,术后即刻造影示破口封闭,无内漏。术后无胸痛,无神经系统并发症,无内漏,术后住院时间（4.5±1.1）d,3-7 d。5例术后发热,吲哚美辛治疗1个月,体温正常。21例主动脉夹层术后1周CT扫描显示真腔扩大,血供明显改善,胸主动脉假腔内血栓形成,腹主动脉假腔存在,开口于假腔的分支靠远端破口供血;5例假性动脉瘤CT扫描显示破口封闭,假腔内血栓形成;2例壁内血肿CT扫描显示溃疡被支架覆盖。23例随访（21.3±10.2）月（1-40个月）,无并发症发生。结论主动脉腔内支架隔绝术疗效可靠,操作简单,创伤小,患者恢复快,并发症少,住院时间短。B型主动脉夹层、降主动脉假性动脉瘤和降主动脉壁内血肿均可采用腔内支架隔绝术治疗。     

Endovascular stent-graft repair for penetrating atherosclerotic ulcer in the infrarenal abdominal aorta

PURPOSE: Penetrating atherosclerotic ulcer (PAU) is an ulceration of an atherosclerotic plaque penetrating through the intima, which may lead to intramural hematoma, aneurysm formation, or rupture. This disease is predominantly found in the thoracic aorta and is uncommon in the infrarenal aorta. The effectiveness of endovascular repair of PAU in the infrarenal aorta was retrospectively investigated. METHODS: From 1999 to 2002, PAU was diagnosed with computed tomography and magnetic resonance imaging in the abdominal aorta in four patients. All patients were men; their average age was 78 years. All four patients had hypertension, and two patients had concomitant coronary artery disease. Three patients had abdominal pain or lumbago. RESULTS: All patients underwent endovascular grafting with a Gianturco Z-stent covered with thin-wall woven Dacron graft. Indications for endovascular intervention were aneurysm formation with or without intramural hematoma in two patients and contained rupture with extraaortic hematoma in two patients. The postoperative course was uneventful in all cases, and no endoleak or aneurysm expansion was recognized during follow-up (4-32 months; average, 14 months). CONCLUSIONS: Infrarenal aortic lesions caused by PAU were generally localized, and endovascular grafting appears to be a feasible alternative to surgical repair.     

Penetrating atheromatous ulcers of the aorta

THORACIC PAINFUL SYNDROME: Penetrating atherosclerotic aortic ulcers represent a condition in which an atherosclerotic plaque ulcerates and disrupts the internal elastic lamina, allowing intramural hematoma formation into the aortic media. Recently individualized as an entity from all vascular thoracic painful syndromes, they affect preponderantly the elderly patients with a medical hypertensive and atherosclerotic history and with multiple cardiovascular risk factors. The descending thoracic aorta is most frequently involved. IMAGING: Computed tomography scanning and magnetic resonance imaging tend to replace aortography in providing an accurate diagnosis of the ulceration and of its parietal extent. Moreover, they allow the discrimination with aortic dissection or with intramural hematoma without intimal rupture which outcome and treatment should differ. RISKS: In the absence of complication, progressive aneurysmal dilatation at the level of the ulcer is a rule. Pseudoaneurysms formation, embolization, and acute transmural aortic rupture can however occur and may justify, in selected cases, a preventive or curative surgical treatment. STENT-GRAFTING: Endovascular stent-grafting techniques may appear as a safe and effective less invasive choice in high-risk patients with suitable anatomical conditions.     

Endovascular treatment of an acute ascending aortic intramural hematoma

INTRODUCTION

Herein, we present a case of an elderly gentleman who presented with an extensive intramural hematoma of the aorta which was treated with a percutaneous placement of an endovascular stent.

PRESENTATION OF CASE

A 79-year-old male with a history of hypertension presented to the emergency department because of sudden onset of substernal chest pain radiating to his back. A chest computerized tomography scan was performed that demonstrated a Type A aortic wall intramural hematoma involving the arch and ascending aorta dissecting both antegrade and retrograde from a penetrating ulcer located in the descending aorta, immediately distal to the left subclavian artery. No dissection flap was noted. The patient opted for an endovascular approach. He was treated with the placement of a stent just distal to the left subclavian artery, with good results noted on follow-up exam performed 3 months later.

DISCUSSION

The treatment of a Type A IMH lacks consensus, but the majority do favor surgical management. The data are limited; however, there are reports of patients with Type A intramural hematoma treated with descending aortic endograft at the site of the culprit ulcerated plaque, with satisfactory results.

CONCLUSION

In a select group of patients, an endovascular approach for the treatment of a Type A aortic wall intramural hematoma caused by an ulcerated plaque may be a viable treatment option.     

Spontaneous nontraumatic rupture of the thoracic aorta: report of a case

Spontaneous nontraumatic rupture of the thoracic aorta is a very rare, life-threatening condition for which emergency diagnostic and therapeutic measures are indicated. The patient reported herein suffered a spontaneous rupture of the thoracic descending aorta through an atheromatous plaque without aneurysmal formation. When acute intrapericardial, mediastinal, or intrapleural bleeding develops without any evidence of aortic aneurysm or dissection, the possibility of spontaneous rupture of the thoracic aorta should be considered in the differential diagnosis, and appropriate emergency surgery may be life-saving. Received: April 17, 2000 / Accepted: March 6, 2001     

Simultaneous Minimally Invasive Direct Coronary Artery Bypass and Repair of a Penetrating Atherosclerotic Ulcer of the Descending Thoracic Aorta: Report of a Case

A 70-year-old man with a descending aortic aneurysm was admitted to the hospital because of an abnormal chest X-ray. The chest computed tomography and magnetic resonance angiography findings showed a saccular aneurysm at the descending thoracic aorta. A preoperative coronary arteriogram showed 75% stenosis of the left anterior descending coronary artery and 99% stenosis of the right coronary artery. A simultaneous minimally invasive direct coronary artery bypass (MIDCAB for two vessels) and a descending aortic aneurysm repair were performed without any complications. A pathological examination showed the aneurysm to be a pseudoaneurysm originating from a penetrating atherosclerotic ulcer. Received: December 25, 2000 / Accepted: July 17, 2001     

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??Diagnosis and treatment of acute aortic syndrome ZHANG Xi-wei, YANG Hong-yu, SUN Peng, et al.Department of Vascular Surgery, the First Affiliated Hospital of Nanjing Medical University,Nanjing 210029 , China
Corresponding author: ZHANG Xi-wei, xiwei1092@yahoo.com.cn
Abstract Objective To explore the diagnosis and treatment of acute aortic syndrome including acute aortic dissection, intramural aortic hematoma and penetrating atherosclerotic aortic ulcer. Methods From Sep. 2004 to Jan. 2009, 126 cases of acute aortic syndrome were admitted. Among them, 98 cases with Standford B type aortic dissection received endovascular repair,19 cases with intramural aortic hematoma received medication therapy, 8 cases with penetrating atherosclerotic aortic ulcer received endovascular repair. 1 patient refused endovascular repair for economic reseaon. Some cases underwent arterial by-pass before endovascular repair on demanding. The time of follow-up was 3 months to 3years.The rate of follow-up was 78%. Results One case with Standford B type aortic dissection died from acute Standford A type aortic dissection 6 months after endovascular repair. One case with intramural aortic hematoma died from acute Standford A type aortic dissection during medication therapy. One case with Standford B type aortic dissection did not recover from ischemia nerve injury of the legs totally after endovascular repair. The others were cured without serious complications. Conclusion Endovascular repair is a safe and effect method of Standford B type aortic dissection and penetrating atherosclerotic aortic ulcer. The indications could be increased by arterial by-pass. The results of medication therapy on intramural aortic hematoma were acceptable.     

Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta

OBJECTIVE: Most studies on variant forms of aortic dissection--penetrating ulcer and intramural hematoma--have focused on the initial presenting episode, with scant follow-up. This investigation provides midterm follow-up of penetrating ulcer and intramural hematoma to determine whether the aorta shows healing according to radiography, goes on to dilate, or tends to rupture during later follow-up. METHODS: Forty-five patients with penetrating ulcers (n = 26) or intramural hematomas (n = 19) were treated at our institution. Ten patients with penetrating ulcers were male and 16 were female, and their ages ranged from 54 to 87 years (mean 72 years). Eight patients with intramural hematomas were male and 11 were female, and their ages ranged from 54 to 88 years (mean 74 years). These patients all had symptoms of aortic disease. Patients with incidental imaging findings were not considered. RESULTS: In the group with penetrating ulcers, rupture occurred during the initial admission in 10 (38%) cases, 17 patients (65%) underwent surgery, and 22 patients (85%) survived to hospital discharge. Among those with intramural hematomas, rupture occurred during the initial admission in 5 cases (26%), 7 patients (37%) underwent surgery, and 16 patients (84%) survived to hospital discharge. Follow-up ranged from 1 month to 12.5 years (mean 3.4 years). No ischemic vascular complications occurred. Imaging follow-up was available for 26 of the 45 patients. Of these, 19% of lesions showed resolution, 23% had worsened, 39% had progressed to typical dissection, and 19% were unchanged. Six late deaths were known to be caused by rupture. In the group with penetrating ulcers, aortic diameter increased from 4.8 to 5.1 cm during the course of 14 months. In the group with intramural hematomas, aortic diameter increased from 5.3 to 5.9 cm during the course of 21 months. Overall survivals were 80% at 1 year, 73% at 3 years, and 66% at 5 years. CONCLUSIONS: Intramural hematoma and penetrating ulcer are lesions associated with advanced age. Women predominate. Penetrating ulcer and intramural hematoma rupture both early and late. Radiographically documented worsening, improvement, or frank dissection may occur with time. Aortic growth does occur (0.2 cm per year for penetrating ulcer and 0.4 cm per year for intramural hematoma). Vascular ischemic complications do not occur. Because of the high early rupture rate, the frequency of radiographic worsening, and the documented occurrence of late rupture, we now recommend surgical replacement of the aorta for these virulent vascular lesions as long as the patient's comorbidities do not preclude surgical intervention.