Elsevier

Annals of Vascular Surgery

Volume 31, February 2016, Pages 8-17
Annals of Vascular Surgery

Clinical Research
The History of Incidentally Discovered Penetrating Aortic Ulcers of the Abdominal Aorta

https://doi.org/10.1016/j.avsg.2015.08.028Get rights and content

Background

The management of incidentally discovered penetrating ulcers of the abdominal aorta (PUAA) is not well described.

Methods

A search of computed tomography (CT) angiography imaging reports for the words “penetrating ulcer” was performed from October 2010 to August 2011. Patients with a PUAA were identified, and their clinical course was followed through December 2014 (n = 53). No specific intervention for the ulcers was sought unless additional aortic pathology necessitated intervention. Prospective and retrospective review of imaging was performed by dedicated vascular radiologists. Aortic diameters and ulcer dimensions were measured for patients with repeat imaging. Mann–Whitney U, Fisher’s exact, and Pearson correlation coefficient tests were performed for statistical analysis.

Results

The calculated incidence of PUAA for patients undergoing CT imaging was 0.48%. Age at diagnosis was 71.6 ± 10.5 years in a population that included 35 (66.0%) males. Repeat imaging was performed for 29 (54.7%) patients. Median clinical and imaging follow-up was 36 (1–127) months and 34 (1–89) months. A history of hypertension (92.5%), hyperlipidemia (77.4%), and tobacco use (81.8%) was common. Twenty-seven (50.9%) had concomitant aneurysms not necessarily associated with PUAA. No aortic aneurysm or PUAA rupture occurred, but the population was sick with 19 patients (35.8%) deceased at the end of the study. Median aortic diameter growth rate through the PUAA was 0.5 (0–11.4) mm/year. No difference in mortality or aortic pathology was detected in patients with aortic growth rates >1 mm/year compared with <1 mm/year (P = 0.21 and P = 0.71, respectively).

Conclusions

Patients with PUAA in general are elderly with multiple comorbidities. A large percentage of patients have concurrent, separate, aortic pathology, most frequently aortic aneurysms. Small changes in the appearance of the PUAA were frequent but did not equate with abdominal aortic catastrophe. Long-term mortality for this population was high, but the ulcer growth during follow-up did not suggest PUAA treatment would improve survival.

Introduction

Penetrating aortic ulcers (PAU) are increasingly recognized as a significant pathology within the spectrum of acute aortic syndromes. The lesions were first described as atheromatous ulcers within the thoracic aorta.1 The ulceration by definition penetrates the intimal elastic lamina layer of the aorta, sometimes with extension into the aortic media and can be associated with the formation of an intramural hematoma. The lesion has also been known to penetrate the adventitia resulting in pseudoaneurysm formation.2 The majority of studies to date describe PAU in the ascending and descending thoracic aorta.2, 3, 4, 5, 6 A large percentage of patients followed in these studies were symptomatic with chest or back pain, often presenting in hypertensive crisis. The rupture rates associated with thoracic PAU during initial hospitalization varied, but in some instances approached 38%.3, 4 Aortic growth rates associated with thoracic PAU is 0.2 cm/year.4 The potentially high rupture rate for the symptomatic patient with a thoracic PAU has resulted in many favoring treatment at presentation.2, 7 Some groups have investigated the efficacy of endovascular repair for these lesions because the patients affected with PAU are generally elderly and not optimal candidates for open repair.5, 6 Their findings suggest these lesions can be treated endovascularly with both a high rate of technical success and patient survival.5, 6

PAU can also occur in the abdominal aorta; however, their incidence is believed to be rare compared with thoracic PAU.8 A few reports have documented success rates with endovascular management of penetrating ulcers of the abdominal aorta (PUAA) in symptomatic patients or in patients with worsening radiologic findings.9, 10, 11 Few studies have investigated the natural history of PUAA.8, 12, 13 Given the paucity of data on these lesions, we elected to review the natural history of PUAA and to determine the need for repair based on growth of the aorta or the PUAA. We performed a simultaneous investigation of the natural history of penetrating ulcers of the iliac arteries.14

Section snippets

Methods

A retrospective review of all patients undergoing computed tomography angiography (CTA) at the University of Virginia Health System, Charlottesville, Virginia (UVa) during a 10-month period between October 2010 and August 2011 was performed. With the advent of electronic medical records, a search for the words “penetrating ulcer” within imaging reports became possible. The presence of a penetrating ulcer was confirmed by 2 independent radiologists specifically trained in cardiovascular imaging

Results

A total of 11,044 abdominal CT scans were performed during the period. Eighty-five patients were identified as having a PAU. A total of 53 patients were identified with a PUAA for an incidence of 0.48%. Age at diagnosis was 70.5 (50.9–93.2) years with 35 (66.0%) male. Age at study conclusion was 74.8 (58.2–98.0) years. Clinical follow-up was 36.0 (0–127) months. Nineteen (35.8%) patients were deceased at the end of the study period. Clinical follow-up for the patients alive at the end of the

Discussion

The natural history of thoracic PAU has been studied in multiple case series and depending on associated features; ulcer progression can be variable and disastrous. Thoracic PAU especially when found in association with intramural hematomas have a higher likelihood of degeneration into saccular aneurysms or rupture.15 Interestingly, in our series, no PUAA were associated with intramural hematomas.

Furthermore, the risk for aortic rupture in patients with symptomatic penetrating ulcers associated

Conclusions

In summary, the natural history of incidentally discovered PUAA is less ominous than PAU of the thoracic aorta and other symptomatic PAU. The inciting event for the development of PUAA is unknown, but most patients are elderly and have hypertension. Most PUAA are incidental and asymptomatic. The growth rate of PUAA is slow and management, in general, should be conservative. Follow-up with serial thin-slice CTA imaging should be performed. Imaging of the entire aorta should also be performed as

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