Contained Rupture in Non-aneurysmal Aorta: 10 Years' Experience of Endovascular Repair of Penetrating Aortic Ulcers in Urgent and Elective Setting

Abstract

Introduction: Penetrating Aortic Ulcers (PAU) are atherosclerotic lesions leading to rupture of the arterial wall even in non-aneurysmal vessels. The incidence of PAU has increased due to a wider use of diagnostic tools, however presentation, natural history, and technical treatment details are not clearly defined. Aim of the study is to analyze a monocentric 10 years' experience of urgent and elective PAU treatment. Methods: Pre, intra and post-operative data of all consecutive patients treated for PAU from 2009 to 2019 were retrospectively analyzed. Pre-discharge, 30-day and follow-up outcomes of patients treated electively and urgently were evaluated and compared. PAU, intended as ulcer-like projection into the medial lining of an artery with aspect of rupture, is characterized by a “neck” (length of intimal defect at the ulcer site), “depth” (its extension outside the aortic wall) and “maximum aortic diameter” at that level (DIAM). PAU with “depth” >20mm or DIAM >40mm were treated and included in the study. Fisher's exact test and T-student test were used for statistical evaluation. Results: Seventy-one patients (age:78±8 years; M 60-85%; F 11-15%; DIAM 51.2±19.2mm, neck 23.3±11.23mm, depth 29.6±17.58mm) were included in the study. Fifty-three patients (M 85%) were treated electively; 18 patients (M 83%) had symptoms (10-56% back/abdominal pain, 2 intestinal occlusions, 2 rectorrhagia, 2 hemorrhagic shock, 1 thoracic pain, 1 unspecified pain) and were treated urgently. Elective and urgent patients had similar characteristic except for Age (Elective:76±7 vs Urgent:81±7 years; p=.03) and ASA score (Elective:3.3±0.5 vs Urgent:3.7±0.5; p=.04). PAU were located in the infrarenal (39 cases-55%), para-visceral (7-10%), and thoracic aorta (10-14%) and in the iliac arteries (15 -21%). No differences among the aortic level presentation was found in the two groups, however there was a significant difference in “depth”(Elective:25.1±17.54mm vs Urgent:42.89±17.67mm; p=.0001) and DIAM (Elective:46.77±19.20mm vs Urgent:64.44±20.17mm; p=.0001) of PAU. All patients were treated by endovascular repair: urgent procedures required more General Anesthesia (Elective:51% vs 78%;p=.003) and more Intensive Care Unit (Elective:49% vs 78%;p=.003). Thirty-day complications occurred in 6 (8%) cases, with one surgical conversion, one iliac occlusion and femoral-femoral crossover bypass, one post-operative nephrectomy and one post-operative dialysis; 30-days mortality occurred in 2 (3%) cases, all in the urgent group (Elective 0% vs Urgent 11%; p=.01). The mean follow-up was 21±20.73 months: 10 cases (14%) had an Endoleak (8 type II, 1 type Ia, 1 very low type III), 2 patients (3%) needed a late Redo (1 Chimney for visceral vessels for proximal aortic rupture, 1 surgical for late anastomotic disruption). There was no difference in the long-term analysis between elective vs urgent treated patients. Conclusion: Endovascular treatment is an effective treatment for PAU; when it is performed electively, perioperative mortality/morbidity is very low with good long term results. Urgent cases have higher mortality rates and need more extensive anesthesiology support, with long-term results similar to non-urgent cases. According to these results, endovascular repair can be proposed as a safe and durable option in patients with PAU and elective repair should be encouraged. Disclosure: Nothing to disclose