TEVAR FOLLOWING A PENETRATING AORTIC ULCER COMPLICATED WITH A LATE PSEUDOANEURYSM FORMATION
Introduction: The thoracic aortic diseases are a major cause contributing to the high mortality rate of the cardiovascular disease. Recent high resolution radiologic studies have allowed us to get new perspectives related to their etiopathogenesis and the different stages of the acute aortic syndrome (AAS).
Clinical case: This case report is about a 51 years old male patient that was referred to the ER with a sudden, acute and abrupt thoracic pain with dorsal irradiation. Also associated were high blood pressure values. An angioCT was immediately performed which showed a penetrating aortic ulcer (PAU) at the descending thoracic aorta with a parietal thickening (suggestive of intramural hematoma — IMH). After 72h of best medical treatment a new angioCT was done which was overlapping. So, it was decided to discharge the patient at the fifth day of hospital stay. At 6 months a new CT was done, this time showing regression of the intramural hematoma but a progression of the PAU to a false aneurysm. Given the new findings it was decided to perform a thoracic endovascular repair. The patient was, then, discharged at the second post-operative day without symptoms with an angioTC showing successful exclusion of the lesion without further complications.
Discussion and Conclusion: The PAU usually results from the erosion of an atherosclerotic plaque which can then be complicated by an IMH, pseudoaneurysm formation or progression to an aortic dissection or rupture. It should be noted that the evolution and subsequent natural history of these pathologies remains, still, not totally clear. The clinical report hereby described reinforces the understanding of the IMH, the PAU and the aortic dissection as different stages of the same disease. We hope to see, in the future, new data related to this disease pathophysiology and respective treatment.
2. Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008;85:S1e41.
3. Svensson LG, Labib SB, Eisenhauer AC, Butterly JR. Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation 1999; 99:1331e6.
4. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, et al. Diagnosis and management of aortic dissection. Eur Heart J 2001;22:1642e81.
5. Sundt TM. Intramural hematoma and penetrating aortic ulcer. Curr Opin Cardiol 2007;22:504e9.
6. Shennan T. Dissecting aneurysms. Medical research council, special report series Nº 193. London: HMSO; 1934.
7. Stanson AW, Kazmier FJ, Hollier LH, Edwards WD, Pairolero PC, Sheedy PF, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1986;1:15e23.
8. Vilacosta I, San Roman JA, Aragoncillo P, Ferreiros J, Mendez R, Graupner C, et al. Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography. J Am Coll Cardiol 1998;32:83e9.
9. Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, et al. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg 2015;47: 1037e43.
10. Coady MA, Rizzo JA, Hammond GL, Pierce JG, Kopf GS, Elefteriades JA. Penetrating ulcer of the thoracic aorta: what is it? How do we recognize it? How do we manage it? J Vasc Surg 1998;27:1006e15.
11. Tittle SL, Lynch RJ, Cole PE, Singh HS, Rizzo JA, Kopf GS, et al. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta. J Thorac Cardiovasc Surg 2002;123:1051e9.
12. Management of Descending Thoracic Aorta Diseases Clinical — Practice Guidelines of the European Society for Vascular Surgery (ESVS). Europ Journal Vasc Endov Surg 2017 53,1,4-52
13. Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: part I: from etiology to diagnostic strategies. Circulation 2003;108:628e35.
14. Nienaber CA, Sievers HH. Intramural hematoma in acute aortic syndrome; more than one variant of dissection? Circulation 2002;106:284e5.
15. Nathan DP, Boonn W, Lai E, Wang GJ, Desai N, Woo EY, et al. Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg 2012;55:10e5.
16. Grimm M, Loewe C, Gottardi R, Funovics M, Zimpfer D, Rodler S, et al. Novel insights into the mechanisms and treatment of intramural hematoma affecting the entire thoracic aorta. Ann Thorac Surg 2008;86:453e6.
17. Geisbüsch P, Kotelis D, Weber TF, Hyhlik-Dürr A, Kauczor HU, Böckler D. Early and midterm results after endovascular stent graft repair of penetrating aortic ulcers. J Vasc Surg 2008;48: 1361e8.
18. Eggebrecht H, Plicht B, Kahlert P, Erbel R. Intramural hematoma and penetrating ulcers: indications to endovascular treatment. Eur J Vasc Endovasc Surg 2009;38:659e65.
19. Clough RE, Mani K, Lyons OT, Bell RE, Zayed HA, Waltham M, et al. Endovascular treatment of acute aortic syndrome. J Vasc Surg 2011;54:1580e7.