The challenge of associated intramural hematoma with endovascular repair for penetrating ulcers of the descending thoracic aorta

Abstract

The presence of penetrating aortic ulcers (PAUs) of the descending thoracic aorta has been associated with a poor long-term prognosis. Although early results have suggested acceptable outcomes for thoracic endovascular aortic repair (TEVAR) for PAU, few studies have described the late outcomes of this approach. From 1993 to 2009, 37 patients (43.2% male; mean age, 72 years) underwent TEVAR for PAU. Associated intramural hematoma was present in 19. Comorbidities included hypertension in 31, chronic obstructive pulmonary disease in 16, coronary artery disease in 22, and renal failure (mean preoperative creatinine, 1.4 mg/dL). Urgent or emergent indications were identified in 22 patients (59.5%), including presentation with rupture in 15 (40.5%). TEVAR was successfully performed in all patients. Arch repair was performed in 14 and total descending repair in 13. Concomitant procedures included coronary artery bypass grafting (CABG) and total arch debranching in one patient electively presenting with an asymptomatic PAU. Early morbidity included stroke (5.4%), temporary paraplegia (5.4%), and need for dialysis (2.7%). In-hospital or 30-day mortality was seen in two patients (5.4%). By Kaplan-Meier analysis, median survival was 89.8 months. Independent predictors of late mortality included urgent or emergent presentation (odds ratio, 14.7; P = .007). Actuarial freedom from TEVAR treatment failure (ie, need for open or endovascular aortic reintervention, aortic rupture, or aortic-related death) was 81.6% +/- 7.8% at 5 years. Analysis stratified by type of pathology (PAU vs PAU and intramural hematoma) showed no significant baseline differences in age, comorbidities, or extent of repair. By Kaplan-Meier analysis, however, presentation with PAU and intramural hematoma was associated with an increased risk for TEVAR treatment failure (P = .033). TEVAR can be safely accomplished for patients presenting with PAU. The presence of associated intramural hematoma may adversely affect the late outcomes of therapy, highlighting the need for careful planning, prudent balancing of the benefits of immediate vs delayed treatment of the fragile aortic wall, and the imperative nature of attentive follow-up in patients with PAU.