Ruptured Penetrating Aortic Ulcer in the Ascending Aorta Treated with Two Parallel Stent Grafts

Abstract

Editor: Penetrating aortic ulcers (PAUs) are seen in 2.3%–7.6% of patients presenting with acute aortic syndrome. They usually penetrate through the intima into the media, and their occurrence may precipitate intramural hemorrhage and dissection. Further penetration to the adventitia may lead to pseudoaneurysm formation with contained or even free rupture. PAU has a high rate of aortic rupture. Most PAUs develop in the descending thoracic aorta. Although they are rare in the ascending aorta, these cases generally require surgical resection (1,2). We present a case in which emergent thoracic endovascular repair was performed in a patient with a ruptured PAU in the ascending aorta. An 83-year-old woman with long-standing hypertension presented with severe chest pain. There was no history of diabetes mellitus, stroke, or smoking. Her medications included amlodipine, bisoprolol, and candesartan for her hypertension. Her blood pressure fluctuated between 90/50 mm Hg and 70/40 mm Hg. Electrocardiography showed sinus bradycardia with complete left bundle branch block. Chest radiography showed marked cardiomegaly, mediastinal widening, and a left pleural effusion. Computed tomography (CT) of the chest showed aneurysmal dilation of the ascending aorta measuring 65 mm in greatest diameter, an atherosclerotic penetrating ulcer in the ascending aorta, and an intramural hematoma from the ascending aorta to the descending aorta (Fig, a). Other scan images showed hemothorax and a large pericardial effusion. Emergent surgical repair was proposed, but was refused by the patient and her family because of her advanced age. Considering the patient’s hemodynamic instability and the cardiac tamponade, emergent endovascular repair was undertaken. Informed consent was obtained from