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Objectifs To understand the etiology and development of the acute aortic syndromes. Understand the key features of the different entities comprising the Acute aortic syndromes. Messages a retenir The acute aortic syndromes comprise of an overlapping spectrum of disorders which may hâve a variety of inciting etiologies : hypertension, cystic medial necrosis, atherosclerosis. Further progression of disease involves decreased integrity of the aortic intima which is exacerbated by increased wall stress. Each of the aortic syndromes hâve characteristic features which help identify the form of disease and help in categorization : aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer. Resume Acute aortic syndromes carry significant morbidity and mortality, especially when detected late. Understanding the pathophysiology and radiologie features of acute aortic syndromes is critical in optimal and timely diagnostic evaluation.

A 73-year-old man was referred for multiple blunt trauma after an automobile accident with drowsy mentality. At the time of impact, he sat unstrained in the back seat behind the driver. To evaluate the organ damages, brain and chest computed tomography (CT) scans were performed. The chest CT with sagittal reconstruction showed 2 separate contrast-filled false lumens composed of ruptured intimal flaps in aortic arch and descending thoracic aorta. The lesions communicated directly with the aortic lumen. The proximal lesion in aortic arch, occurred just above the left subclavian artery, had 8 mm-depth ulceration into the aortic media and the distal lesion in descending aorta had 5mm-depth ulceration into the aortic media, mimicking penetrating atherosclerotic ulcer. Also, multiple atherosclerotic plaques were found in the whole thoracic aortic wall (Fig. 1). Transesophageal echocardiography (TEE) of the aorta showed similar findings with chest CT. The continuity of endothelium was completely disrupted and 2 separate false lumens were made due to endothelial detachment. The ruptured endothelium of proximal lesion was highly movable. During systole, it disturbed the aortic flow (Fig. 2A). The distal lesion didn't disturb the aortic flow (Fig. 2B). Fig. 1 The chest CT with sagittal reconstruction. The proximal dissection (*). The distal dissection (arrow). Fig. 2 Transesophageal echocardiography, color Doppler. Proximal dissection (A), distal dissection (B). Dissection of the aorta after blunt chest trauma usually occurs at the level of ligamentum arteriosum just distal to the left subclavian artery. However, in our case, the lesions occurred at unusual sites. We suggest that the decelerating force propagated through the aortic wall may cause underlying atherosclerotic plaques breakage forming endothelial detachment and rupture at unusual sites.

Penetrating atherosclerotic ulcer (PAU) of infrarenal aorta is a rare but life-threatening entity affecting elderly patients with severe atherosclerotic disease, and potentially complicated with intramural hematoma, adventitial pseudoaneurysm or aortic rupture. Although open surgical repair is an effective therapeutic option, endovascular treatment is emerging as an attractive alternative, especially in high-risk elderly patients. We report our experience with four cases of endovascular stent-grafting of infrarenal aorta PAU. All patients presented with abdominal or lumbar pain, and two of them with shock. The diagnosis was based on CT scan and angiography that demonstrated infrarenal pseudoaneurysm in two and focal nonaneurysmal infrarenal aortic rupture in the other two patients, secondary to PAU. Endoluminal transfemoral stent-grafting was successfully delivered in all patients. One of them died 5 days after the intervention because of multiple organ failure. During a mean follow-up period of 24 months, no endoleak, aneurysm evolution or stent-graft failure were found in the remaining three patients.

Background In this study we evaluate published and personal experience of Endovascular Repair (EVAR) of penetrating atherosclerotic ulcers (PAU). Patients and method In 12 patients (mean 74 years, 58–87 years) PAU was diagnosed with computer tomography (CT). Symptomatic ulcers were treated by vascular surgeons using stentgrafts via a femoral access route. Patients were followed up clinically and with CT for an average of 849 days (186–1968 days). Results 11 patients had severe acute thoracic pain, one patient presented with hemoptysis. CT showed well outlined ulcer, intramural hematoma, and contrast enhancement of the aortic wall (n = 12), pseudoaneurysm (n = 11), intimal calcification adjoining the ulcer (n = 10), pleural (n = 9) and mediastinal fluid (n = 4). Mean duration of surgery was 68 min (32–120 min). Primary technical success was achieved in all patients. There was no perioperative complications except one acute hemorrhage from an intercostal artery and one iliac dissection. 3 months after stentgraft application owing to a severe stenosis of the right common femoral artery, an iliofemoral bypass was performed in one patient. All patients were free of symptoms after the procedure. There was incomplete sealing of PAU in 2 of 12 patients, but no re-intervention was needed. All patients were alive during follow-up. Conclusion Symptomatic PAU is a potentially fatal lesion. Considering the low morbidity and mortality of EVAR, this option might be first choice.

Aortic dissection is a life-threatening condition which is difficult to diagnose because of its variable clinical presentation and diverse pathophysiologic manifestations. We present a case in which intramural hematoma of the thoracic aorta occurred in the absence of an intimal flap. Computed tomography and magnetic resonance imaging both showed hemorrhage in the wall of the aorta. Transesophageal echocardiography also revealed a penetrating atherosclerotic ulcer in the transverse aorta as a cause of the hematoma. A high index of clinical suspicion and a combination of diagnostic procedures resulted in proper diagnosis and successful surgical treatment.

A contained rupture of the aorta is a rare event; however, this has been recognized with increased frequency in the abdominal aorta. There have previously been two reports of the containment of rupture of the suprarenal aorta. We report two additional cases of contained rupture of the suprarenal aorta, one caused by a penetrating atherosclerotic ulcer, the other from a ruptured aneurysm. Surgical treatment was successful in both patients. (J VASC SURG 1987;5:651-4.)

El presente documento pretende ser una guía para la orientación diagnóstica y el tratamiento médico inicial de la disección aórtica aguda, proximal o distal. Esta entidad constituye una complicación catastrófica de la enfermedad aórtica, con consecuencias a menudo fatales, y cuyo abordaje exige procedimientos diagnósticos y de tratamiento medicoquirúrgico que, con frecuencia, se llevarán a cabo fuera de la jornada de trabajo habitual y, en ocasiones, por personal con experiencia insuficiente. Estas circunstancias obligan, por una parte, a ser flexibles y adaptarse a las condiciones locales a la hora de planear la estrategia diagnóstica y de tratamiento y, por otra, reiteran la importancia de la existencia de guías de actuación que faciliten un abordaje estandarizado del problema. No pretendemos hacer una revisión exhaustiva del tema, pues el objetivo es dar pautas de manejo a personal con formación completa. Tampoco entramos en la descripción o discusión de las diferentes técnicas quirúrgicas aplicables en la disección aórtica, pues entendemos que esto excedería el objetivo inicial del documento y, además, invadiría el margen de actuación del cirujano, que deberá estar condicionado por su propio entrenamiento y experiencia clínica personal.The aim of the present document is to be a guide for the diagnostic approach and initial medical management of acute aortic dissection, be it proximal or distal. This entity constitutes a catastrophic complication of aortic disease, frequently with lethal consequences, whose management requires diagnostic and therapeutic procedures that will often take place in the middle of the night and, some times, will be performed by insufficiently experienced personnel. These circumstances impose, on one hand, the need to be flexible and adapt to local conditions when planning the diagnostic and treatment strategy, but also, underscore the importance of developing management guidelines that facilitate a standardized approach to this difficult problem. We do not intend herein to accomplish a comprehensive revision of the topic, since our aim is to give management advice to personnel with complete training. Neither do we discuss the variety of surgical techniques that are used for the treatment of acute aortic dissection, since this would extend beyond the scope initially planned for the document and, also, would invade the limits of the surgeon's liberty of practice, that should be conditioned by his own training background and individual clinical experience.

ObjectiveThis study assessed the vascular distribution of stroke after thoracic endovascular aortic repair (TEVAR) and its relationship to perioperative death and neurologic outcome.MethodsA retrospective review was performed for patients undergoing TEVAR between 2001 and 2010. Aortic arch hybrid and abdominal debranching cases were excluded. Demographics, operative variables, and neurologic complications were examined. Stroke was defined as any new focal or global neurologic deficit lasting >24 hours with radiographic confirmation of acute intracranial pathology.ResultsPerioperative stroke occurred in 20 of 530 patients (3.8%) undergoing TEVAR. The cohort was 55% male and a mean age of 75.2 ± 8.9 years (range, 57-90 years). Among patients with perioperative strokes, the indication for surgery was degenerative aneurysm in 14 (mean diameter, 6.8 cm), acute type B dissection in four, penetrating atherosclerotic aneurysm in one, and aortic transection in one. Cases were performed urgently or as an emergency in 60%. The proximal landing zone was zone 2 in 11 or zone 3 in nine. All strokes were embolic. The vascular distribution of stroke involved the anterior cerebral (AC) circulation in eight (zone 2, n = 5) and the posterior cerebral (PC) circulation in 12 (zone 2, n = 6). Laterality of cerebral infarction included five right-sided, eight left-sided, and seven bilateral strokes. Nine strokes were diagnosed

Objective In recent years, thoracic endovascular aneurysm repair (TEVAR) has been attempted for acute aortic emergencies (AAEs). However, the risk factors for achieving good results have not been identified. Besides focusing on Acute Physiology and Chronic Health Evaluation (APACHE) II score as a general indicator of patient condition, we analyzed both preoperative factors and intraoperative/postoperative factors. The purpose of this study was to identify those factors affecting the results of TEVAR using our Matsui-Kitamura stent graft (MKSG) for AAEs involving descending thoracic aortic aneurysm. Methods Between July 2000 and June 2008, a total of 32 patients (23 men, 9 women) with AAEs underwent endovascular repair. AAE was a result of aortic aneurysm rupture in 16 cases, rupture of penetrating atherosclerotic ulcer in 2 cases, traumatic aortic injury in 9 cases, complicated type B dissection in 4 cases, and aortic infiltration of sarcoma in 1 case. Low blood pressure in 6 patients, acute renal failure in 7 patients, anemia due to bleeding in 12 patients were found at the time of operation. Urgent TEVAR using the MKSG was performed. Perioperative and long-term results for these patients were investigated. Results The delivery and technical success rate for TEVAR using the MKSG, was 100%. Perioperative mortality was 12.5%, and 5-year survival rate was 71%. In both univariate and multivariate analysis, the APACHE II score clarified a risk factor. Among the various elements of an APACHE II score, age, hematocrit, and total score were identified as significant factors. The mean of an APACHE II score was 9.5. Patients with an APACHE II score ≥10 showed significantly lower 5-year survival rates than patients with an APACHE II score ≤9. Conclusions Good results were obtained using TEVAR to treat AAEs with MKSGs, both perioperatively and during medium-term follow-up. Evaluation of risk factors for TEVAR of AAEs showed the utility of APACHE II score (particularly age, hematocrit, and total score) with a score ≥10 indicating high risk.

Purpose To evaluate the role of multi-detector CT angiography in acute assessment of patients with acute aortic syndrome (AAS) and discriminating between Intramural hematoma and penetrating atherosclerotic ulcer compared with conventional angiography (CA) as a gold standard technique. Patient and methods 47 patients were recruited in this prospective study, and contrast-enhanced multi-detector CT angiography examinations were performed from the thoracic inlet to the aortic bifurcation. Results The mean ulcer diameter was 1.6 cm. The largest number of lesions was in the part of the distal descending aorta below D8. The mean diameter of aorta at level of ulcer was 3.7 cm. Opacification of false lumen was determined in 6 patients. Intramural hematoma was present in 28 patients; it was identified in unenhanced scans as hyper-attenuated mural crescent. The mean length of false lumen was also evaluated for all patients, and it was 16.4 cm. There was a statistically significant correlation between MDCTA and conventional angiography in determining ulcer diameter ( p = 0.2359), number ( p = 0.5896), location ( p = 0.3659), as well as aortic diameter at level of ulcer ( p = 0.6398). Conclusion Multi-detector CT angiography is an accurate, non-invasive tool which has the ability to detect and characterize aortic PAUs correctly and comparable to conventional angiography.

Background We present a series of patients who underwent in situ total aortic arch replacement for infected distal aortic arch aneurysms. Methods Between 2002 and 2013, 9 patients with infected distal aortic arch aneurysms underwent total aortic arch replacement using antegrade selective cerebral perfusion. There were 4 male and 5 female patients with a mean age of 72.7 ± 9.0 years. All patients had penetrating atherosclerotic ulcer in the distal aortic arch, which formed saccular aneurysms. Four patients had preoperative hoarseness. Maximum preoperative white blood cell count was 10,211 ± 4375/μL, and mean serum C-reactive protein concentration was 12.7 ± 7.2 mg/dL. Causative microorganisms were identified by blood culture or aortic wall culture and were as follows: Candida albicans, Pseudomonas aeruginosa, Edwardsiella tarda, Streptococcus dysgalactiae, Listeria monocytogenes, Staphylococcus aureus (2 cases), and unknown (2 cases). Radical debridement with in situ total aortic arch replacement was performed in all patients, followed by the omental flap grafting in 7 patients. All surgery was performed on an urgent or emergency basis. Results Average cardiopulmonary bypass time and lower body circulatory arrest time were 199.7 ± 50.7 minutes and 66.6 ± 13.8 minutes, respectively. There was no in-hospital mortality, but 1 patient died of asphyxia 5 months after hospital discharge. Freedom from recurrence of infection was 100%. Conclusions Surgical treatment with the combination of radical debridement with in situ total aortic arch replacement using antegrade selective cerebral perfusion and omental flap grafting was a reliable procedure for the treatment of infected distal aortic arch aneurysms.

The term "penetrating aortic ulcer" refers to an ulceration of an atheromatous plaque that extends deeply through the intima and into the aortic media. It may precipitate an intramedial dissection (usually localized) or may rupture into the adventitia to form a pseudoaneurysm. The typical patient with penetrating atheromatous aortic ulcer is elderly and has hypertension, atherosclerosis, and back or chest pain, but pulse deficit, stroke, aortic insufficiency, and compromise of a visceral vessel are not present. Classic aortic dissection and symptomatic thoracic aortic aneurysms are among possibilities in the differential diagnosis. Aortography demonstrates the presence of an aortic ulcer similar in appearance to gastric ulcers seen on barium examination; in addition, an intramural aortic hematoma may be present. Our experience with penetrating aortic ulcers in symptomatic patients indicates that conservative medical therapy leads to recurrence of symptoms and a need for surgical intervention. We present a case that illustrates the salient features of this distinct clinical entity.

Clinically, penetrating atheromatous ulceration of the aortic wall may be confused with either symptomatic thoracic aneurysm or classic spontaneous aortic dissection. Aortography and computed tomographic (CT) scanning of the thoracic aorta provide specific diagnostic information which permits one to distinguish this lesion from atherosclerotic aneurysm and classic dissection. Hallmarks of findings on aortography and CT scan include the presence of the ulcer and an intramural hematoma. Since the findings may be disarmingly subtle, the potentially progressive and serious nature of this condition may remain unappreciated. Recognition of the penetrating atheromatous ulcer and distinguishing it from aortic dissection arising just distal to the origin of the left subclavian artery is mandatory. Resection of only a conservative segment of the proximal descending aorta suffices for classic dissection in the upper descending thoracic aorta, but the penetrating aortic ulcer requires graft replacement in the area of the ulcer and intramural hematoma.

Background Acute aortic syndrome, including classic aortic dissection, intramural aortic hematoma, and penetrating atherosclerotic ulcer (PAU), is a term used to describe a group of conditions with similar clinical symptoms, but with different pathophysiological mechanisms. PAU is a lesion that penetrates the internal elastic lamina through the media. It is usually located in the descending aorta and rarely observed in the ascending aorta. Case presentation A 76-year-old man with a history of essential hypertension was brought to the emergency department (ED) because of a sudden-onset chest pain at rest. He had not been taking his medication as ordered. His vital signs in the ED were a blood pressure of 82/60 mmHg, heart rate of 158 beats per min, respiratory rate of 22 breaths per min, and a body temperature of 37.2 °C. An electrocardiogram did not show an ST segment elevation, and cardiac enzymes were within normal limits. No widening mediastinum was found on chest radiography, but a large pericardial effusion with an impending cardiac tamponade was revealed on echocardiography. The diagnosis of PAU rupture in the ascending aorta with hemopericardium was made with chest computed tomography. An emergent sternotomy and ascending aorta reconstruction were performed. A ruptured ulcerative plaque through the intima to the adventitia without flap dissection in the ascending aorta was confirmed. The patient was discharged 18 days after the operation. Conclusions Although PAU in the ascending aorta is uncommon, it is commonly lethal when it ruptures. With the current advances in endovascular techniques and devices, endovascular repair of PAU in the ascending aorta is currently recommended only for high-risk patients unsuitable for open repair. However, we anticipate that endovascular repair may become feasible in patients with PAU in the ascending aorta in the future.

Endovascular stent grafting has been recently considered as a less invasive alternative to either medical therapy or open surgical treatment for many patients with descending thoracic aortic disease. Late complications are rarely described in literature. Herein, we described the occurrence of an aorto-bronchial fistula and a retro-A dissection in a 73-year-old man after stent-grafting for a penetrating atherosclerotic ulcer (PAU) of the descending thoracic aorta and the successful surgical technique adopted in order to remove the stent-graft.

To the Editor: We agree with Ganaha et al1 that differentiation between the distinct clinical entities of intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU) is essential. Hemorrhage occurs within the aortic wall during IMH despite a nonatheromatous intact intima, whereas secondary medial hemorrhage occurs through an atheromatous disrupted intima in patients with …

Resumo A história natural do hematoma intramural (HI) e da úlcera penetrante (UP) é muito variável, já que podem progredir para a formação de aneurisma, ruptura, dissecção, e podem até mesmo regredir, no caso específico do HI. Exames de imagem têm crescente papel no manejo clínico e operatório da UP e do HI. Ao contrário das projeções semelhantes a úlcera, achados de lagos sanguíneos não são relatados nos estudos tomográficos de pacientes com HI. O entendimento das características da imagem e do curso natural de cada uma dessas entidades ajudará clínicos e cirurgiões a identificar os pacientes com maior risco para um mau prognóstico e pode melhorar os desfechos. A fisiopatologia dessas entidades, as controvérsias no que se refere a suas histórias naturais e os fatores prognósticos das imagens tomográficas são discutidos neste artigo.

Penetrating atherosclerotic ulcer (PAU) of the infrarenal aorta is rare and occurs when an atherosclerotic plaque ulcerates through the intima. PAU can be complicated by the development of intramural hematoma, adventitial pseudoaneurysm, and rupture. We report two cases that were treated by endovascular stent-graft placement and discuss the literature.