**7. Conclusions**

Understanding the defining characteristics of the various acute aortic syndromes is essential as their pathophysiology and potential therapeutic implications are different. Penetrating aortic ulcers are defined by their focal nature and a patient population that tends to be elderly with significant comorbidities. Given these characteristics, endovascular approaches to


**6.3. Operative approach**

380 Principles and Practice of Cardiothoracic Surgery

those treated with an open approach.

atherosclerotic burden of these patients.

**7. Conclusions**

patients.

Open repair of the descending thoracic aorta in patients with penetrating aortic ulcers is a significant operation with mortality rates as high as 15-20% [20, 21]. This is in part a reflection of the advanced age and comorbidity burden of the typical patient with this disease. Given the frequently segmental nature of aortic ulcers and the higher risk patient profile, an endovascular approach to treatment appears particularly well suited. However, it is important to mention that patients with penetrating ulcers typically have extensive atherosclerotic disease, and therefore, access for endovascular delivery of grafts is challenging if not unfeasible in many

A single-center experience with endovascular treatment of penetrating aortic ulcers in 21 patients demonstrated successful deployment in all patients, with no endoleaks or mortalities at 30-days (Table 1) [22]. Another single institution study compared open repair in 37 patients with endovascular repair in 58 patients [23]. The endovascular cohort was significantly older and had a higher frequency of prior cerebrovascular disease. As expected, the open group involved repair of the aortic arch more frequently. The operative mortality rate was 5.1% in the endovascular group, which was one-third of that observed in the open cohort (16.2%; p=0.07). Furthermore, rates of perioperative stroke and prolonged ventilation were higher in

In a European study of 72 patients undergoing endovascular repair of penetrating aortic ulcers, there was an in-hospital mortality rate of 4%, with an early endoleak rate of 7% and late endoleak rate of 4% [24]. Long-term survival was also favorable, with 1-, 5-, and 10-year survival being 93%, 72%, and 60%. Age greater than 75 years was an independent predictor of survival in their analysis. Another European study of 22 patients undergoing endovascular treatment of aortic ulcers similarly demonstrated excellent outcomes, with no in-hospital

Although outcomes of an endovascular approach to penetrating aortic ulcers appear favorable, it is unclear if lower volume institutions or surgeons can attain comparable results to those reported in the literature. Referral to centers with significant experience in endovascular surgery is therefore advisable. Furthermore, open surgical repair will always remain an important component of the treatment armamentarium, as certain ulcers are not anatomically amenable to an endovascular approach due to their location, due to unfavorable aortic dimensions or anatomy, or due to an inability to gain access given the frequently extensive

Understanding the defining characteristics of the various acute aortic syndromes is essential as their pathophysiology and potential therapeutic implications are different. Penetrating aortic ulcers are defined by their focal nature and a patient population that tends to be elderly with significant comorbidities. Given these characteristics, endovascular approaches to

mortalities and no complications aside from stroke in 1 (5%) patient [25].

**Table 1.** Operative Outcomes following Endovascular Repair of Penetrating Aortic Ulcers.

treatment in those with suitable anatomy appear particularly attractive, and indeed, initial reports from experienced centers have demonstrated favorable outcomes. A growing cumu‐ lative experience with penetrating aortic ulcers will hopefully be met with continuing advances and improvements in therapy. This will be particularly important as the population ages and imaging techniques improve, changes that will likely result in increases in the prevalence of this disease.

[8] Botta L, Buttazzi K, Russo V, Parlapiano M, Gostoli V, Di Bartolomeo R, Fattori R. Endovascular repair for penetrating atherosclerotic ulcers of the descending thoracic

Penetrating Aortic Ulcers http://dx.doi.org/10.5772/54107 383

[9] Gottardi R, Zimpfer D, Funovics M, Schoder M, Lammer J, Wolner E, Czerny M, Grimm M. Mid-term results after endovascular stent-graft placement due to pene‐ trating atherosclerotic ulcers of the thoracic aorta. Eur J CardiothoracSurg 2008; 33:

[10] Brinster DR. Endovascular repair of the descending thoracic aorta for penetrating

[11] Hirst AE Jr, Barbour BH. Dissecting aneurysm with hemopericardium: report of a

[12] Lehman SJ, Abbara S, Cury RC, Nagurney JT, Hsu J, Goela A, Schlett CL, Dodd JD, Brady TJ, Bamberg F, Hoffmann U.Significance of cardiac computed tomography in‐

[13] Machaalany J, Yam Y, Ruddy TD, Abraham A, Chen L, Beanlands RS, Chow BJ. Po‐ tential clinical and economic consequences of noncardiac incidental findings on car‐

[14] Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aortic dissec‐ tions: penetrating atherosclerotic ulcers and intramural hematomas. CardiolClin

[15] Cho KR, Stanson AW, Potter DD, Cherry KJ, Schaff HV, Sundt TM 3rd.Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch.J ThoracCardiovasc‐

[16] Hayashi H, Matsuoka Y, Sakamoto I, Sueyoshi E, Okimoto T, Hayashi K, Matsunaga N.Penetrating atherosclerotic ulcer of the aorta: imaging features and disease con‐

[17] Quint LE, Williams DM, Francis IR, Monaghan HM, Sonnad SS, Patel S, Deeb GM. Ulcerlike lesions of the aorta: imaging features and natural history. Radiology

[18] 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

[19] Tittle SL, Lynch RJ, Cole PE, Singh HS, Rizzo JA, Kopf GS, Elefteriades JA. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta. J ThoracCar‐

aorta: early and mid-term results. Ann ThoracSurg 2008; 85: 987-992.

atherosclerotic ulcer disease. J Card Surg 2009; 24: 203-208.

cidental findings in acute chest pain. Am J Med 2009; 122:543-549.

diac computed tomography. J Am CollCardiol 2009; 54: 1533-1541.

case with healing. N Engl J Med 1958; 258: 116-20.

1019-1024.

1999; 17:637–657.

2001;218:719-723.

Surg 2004; 127:1393-1399.

cept. Radiographics 2000; 20:995-1005.

it? J VascSurg 1998; 27:1006-1015.

diovascSurg 2002; 123:1051-1059.
