The natural history of penetrating ulcers of the iliac arteries

Abstract

The natural history of penetrating ulcers of the iliac arteries (PUIA) has not been previously described. The potential for degeneration into pseudoanerysm and rupture are feared complications. It is hypothesized that PUIA, similar to their thoracic aortic counterparts, signal impending vascular catastrophe. A search of computed tomography (CT) angiography reports for the words, "penetrating ulcer" was performed. Patients with PUIA who underwent CT imaging from October 2010 to August 2011 were identified. Their clinical course was followed through December 2014. If patients with PUIA had additional vascular pathology that necessitated intervention, it was performed. A prospective and retrospective review of the imaging was performed when possible. Associated iliac diameter and ulcer dimensions were measured for patients with repeat imaging (n = 22). Demographic characteristics were compared for patients who were identified as having penetrating ulcers of the abdominal aorta. Mann-Whitney U, Fisher exact, and Pearson correlation coefficient tests were performed for statistical analysis. The calculated incidence of PUIA for patients who underwent CT imaging was 0.3%. The age at the time of diagnosis was 70.7 ± 10.0 years and the cohort included 28 male patients (82.3%). Median clinical and imaging follow-up was 42.0 (range, 1-82) months and 40.5 (range, 1-77) months. Most patients had a history of hypertension (82.4%), hyperlipidemia (76.5%), and tobacco use (70.6%). Twenty-one patients (61.8%) had concomitant aneurysms not necessarily associated with the PUIA. Although no PUIA rupture occurred, the population was sick because seven patients (20.6%) were deceased at the study end. Only one individual presented with symptoms that could possibly be attributed to their PUIA. Repeat imaging was performed for 22 patients (64.7%). The calculated median iliac artery diameter growth rate through the PUIA was 0.1 (range, 0-4.1) mm/y. PUIA are generally slow-growing and are found incidentally. Most patients with PUIA were in their eighth decade with a history of hypertension and tobacco use. Patients with PUIA frequently have concurrent aortic aneurysm disease that requires intervention. The mortality for this population was high, but was not caused by rupture of a PUIA. Diameter changes noted in the PUIA during follow-up did not suggest ulcer treatment would improve survival.