Shaun M. Gifford, Audra Duncan, Lawrence Greiten, Peter Gloviczki, Gustavo S. Oderich, Manju Kalra, Mark D. Fleming, Thomas Bower
Vascular Surgery, Mayo Clinic, Rochester, MN.
OBJECTIVES: To define the natural history of penetrating aortic ulcers (PAU) in the descending thoracic (DTA) and abdominal aorta (AA).
METHODS: Data from consecutive patients with PAU from Jan. 1, 1998, to Dec. 31, 2012, were retrospectively reviewed. Computed tomography (CT) was analyzed for anatomical changes. Endpoints were changes in size, symptoms/rupture, morbidity and mortality.
RESULTS: Ninety-three patients were studied: 20 had immediate repair (Group 1), 57 were followed with 2 or more CTs 3 months apart (Group 2), and 16 had 1 CT and no intervention. Group 1 included 13 men, 7 women with a mean age of 70 with 12 DTA and 8 AA PAUs. Group 1 repair indications were: rupture (3), symptoms (10) or size (7). Group 1 repairs included 1 open and 19 endovascular with 0% 30-day mortality. Major complications (3/20 15%) included MI, access site disruption and hematoma; 4/20 had Type II endoleaks. In Group 2, mean age was 75 years (29 men, 28 women) with 28 DTA and 29 AA PAUs. Fifty patients were asymptomatic while 5 had pain and 2 had distal emboli. Mean follow-up was 38 months (range 3-108). Ulcer growth rate was: length 2mm/year, depth 1.2mm/year, and aortic diameter 2.2mm/yr. Thirteen (23%) went on to repair at a mean of 31 months after diagnosis due to size (54%, 7/13), rapid growth (31%, 4/13) and high-risk morphology (15%, 2/13). During surveillance, 11 patients died; 10 of unrelated causes and 1 of rupture after refusing repair. All repairs in Group 2 were endovascular. 30-day surgical mortality was 0%. One patient had an access site complication requiring bypass after DTA PAU repair. At a mean follow-up of 32 months, all ulcers were excluded on CT; 1 (8%) has a Type II endoleak.
CONCLUSIONS: PAU growth rate and risk of rupture are low. Endovascular repair of symptomatic, ruptured and large PAU is safe and effective with excellent long-term results. For asymptomatic PAU, serial CT surveillance is associated with a low rate of rupture or complications.
AUTHOR DISCLOSURES: T. Bower: Nothing to disclose; A. Duncan: Nothing to disclose; M. D. Fleming: Nothing to disclose; S. M. Gifford: Nothing to disclose; P. Gloviczki: Nothing to disclose; L. Greiten: Nothing to disclose; M. Kalra: Nothing to disclose; G. S. Oderich: Nothing to disclose.
Posted April 2013