Penetrating Atherosclerotic Ulcer—Who Should Be Treated?

Abstract

Penetrating atherosclerotic ulcer (PAU) is a disease of the elderly often located in the descending thoracic aorta. It is related to acute dissection and intramural hematoma (IMH) and together they form the entity; acute aortic syndrome (AAS). PAU may be found incidentally in asymptomatic patients undergoing imaging of the chest or in symptomatic patients thought to have a myocardial infarction or AAS. It occurs as a local disruption of the intimal layer of the aorta and progresses into the medial layers, at the site of an atheromatous plaque. Some are associated with an IMH and even significant dissection. Symptomatic patients may present with chest, back or flank pain similar in quality and severity to that seen with acute aortic dissection. Appropriate imaging is important. Management is dictated largely by location with those involving the ascending aorta (type A) generally requiring urgent surgical management while those elsewhere (type B) may be treated more conservatively. Initially patients may be treated medically with anti-impulse therapy consisting of beta-blockade and afterload reduction. Medically managed patients should be followed by aortic specialists with serial CT scan in 3–5 days. Surgical intervention should be considered in patients of acceptable operative risk in cases of refractory pain, acute pseudoaneurysm, rupture, progression of the PAU or IMH, or in those cases of PAU located in the ascending aorta. Open surgical repair with graft interposition may be difficult due to the diffusely diseased aorta in many patients. Most of these patients have extensive atherosclerosis and associated coomorbidities such as renal insufficiency, peripheral vascular disease, cerebral vascular disease and chronic obstructive pulmonary disease. The localized nature of the PAU would seem to be the ideal target for endovascular repair in this often high risk group. Short-term results are encouraging with near 100 % procedural success for thoracic endovascular aortic replacement (TEVAR). Recent results, with longer follow up, suggest that concomitant IMH may adversely affect long term TEVAR results.