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El sindrome aortico agudo (SAA) describe la presentacion aguda en los pacientes de un «dolor aortico» caracteristico, causado por una de las diversas afecciones potencialmente mortales de la aorta toracica, entre las que cabe destacar la diseccion aortica, el hematoma intramural o la ulcera aterosclerotica penetrante. Los recientes avances en el tratamiento y las tecnicas de imagen han puesto de manifiesto la importancia del diagnostico precoz en el sindrome aortico agudo, al ser crucial para la supervivencia. El tratamiento del SAA sigue siendo un desafio terapeutico, en parte porque los conocimientos de la comunidad cardiovascular en este tema son tan solo moderados y tambien porque las diversas estrategias quirurgicas y percutaneas para el tratamiento de los sindromes aorticos estan en continuo desarrollo. El curso clinico de los pacientes tratados por SAA ha mejorado como consecuencia de los mayores conocimientos y las mejores estrategias de tratamiento en este terreno. La presente revision se ocupa de la etiologia y la presentacion clinica, pero sobre todo el tratamiento moderno y los diferentes enfoques terapeuticos, tanto clasicos como recientes, de los SAA.

Acute thoracic aortic syndromes encompass a spectrum of emergencies presenting with acute chest pain and marked by a high risk of aortic rupture and sudden death. These include nontraumatic disease entities of the thoracic aorta, namely, dissection, intramural haematoma, penetrating atherosclerotic ulcer and aneurysm rupture. In clinical practice, the most frequent imaging procedure used in the diagnostic assessment of these diseases is computed tomography (CT), which, thanks to recent technological developments [multidetector-row computed tomography (MDCT)], affords important diagnostic possibilities and very interesting future perspectives. This paper on the use of MDCT in the evaluation of acute thoracic nontraumatic aortic syndromes illustrates the examination technique and the key imaging findings related to each disease. Moreover, the role of MDCT for planning specific treatment is also highlighted.

Intramural hematoma and penetrating aortic ulcer are uncommon but potentially lethal thoracic aortic pathologies. Despite incomplete understanding of their natural history, they have emerged as anatomically appealing targets of endovascular therapy. Appropriate application of these technologies, however, must be predicated on an understanding of the fate of these lesions left untreated, and predictors of their misbehavior. We briefly review the current understanding of these entities.

Acute aortic syndrome (AAS) describes the acute presentation of patients with characteristic "aortic pain" caused by one of several life threatening thoracic aortic conditions including aortic dissection, intramural hematoma or penetrating atherosclerotic ulcer. Recent advances in imaging and therapeutic techniques have emphasized the importance of early diagnosis of acute aortic syndrome because it is crucial for survival. Not just because the cardiovascular community knows little, the management of AAS remains a therapeutic challenge, while diverse surgical and percutaneous strategies for the treatment of aortic syndromes are continuously evolving. As a result of increasing knowledge and better management strategies in this area, the outcomes of patients treated for acute aortic syndromes have improved. This review discusses the etiology and clinical presentation, but mainly focuses on modern management and both established and emerging therapeutic approaches to acute aortic syndromes.

Spontaneous perforation of a nonaneurysmal abdominal aorta due to a penetrating atherosclerotic ulcer (PAU) is exceedingly rare. We describe the case of a 57-year-old man with a perforating PAU of the infrarenal aortic wall and discuss the clinical presentation, diagnostic pathways, and therapeutic options based on a comprehensive review of the literature. Since a PAU of the aorta can give rise to chronic mild to moderate abdominal or back pain, a computed tomographic scan of the abdomen should be performed in patients with evidence of vascular disease and persistent abdominal or back discomfort. Surgical resection or stent-graft placement is indicated in symptomatic patients or in asymptomatic patients with radiographic signs of progressive PAU.

An intimal tear is responsible for the development of aortic dissection (AD). Plaque rupture is thought to progress to a penetrating atherosclerotic ulcer (PAU). However, the influences of mechanical stress and atherosclerosis on the intimal tear of AD and plaque rupture of PAU have not been fully understood. We enrolled 27 patients with AD [67.6 ± 11.2 years, female/male (F/M) 12/15] and 10 patients with PAU (71.0 ± 8.64 years, F/M 2/8) who underwent aortic reconstructive surgery in our hospital between 2007 and 2011. We analyzed the clinical data and morphological features of these patients and discuss the role of mechanical stress in the initial event. On clinical examination, hypertension was frequently observed in the patients of both the AD (77.8 %) and PAU groups (90.0 %), while hypercholesterolemia was significantly more prevalent in the PAU group (90.0 %) than in the AD (22.2 %) group. Most lesions of AD (96.3 %) were found in the ascending aorta up to the aortic arch, while those of PAU (90.0 %) were found in the descending and abdominal aortas. On pathological examination, the entrance tear was found in 21 (77.8 %) of the 27 patients with AD, and histologically comprised nonatherosclerotic intima and media. In contrast, the entrance tear was considered as plaque ulcer in 8 (80.0 %) of the 10 patients with PAU. The patients with PAU showed a significantly higher prevalence of soft plaque, complicated lesions, and medial fibrosis than those with AD, whereas patients with AD showed no complicated lesions and had a significantly higher prevalence of cystic medial necrosis than those with PAU. The present study suggests that less atherosclerosis and impairment of media could proceed to intimal tear formation in AD and that the disruption of the fibrous cap could cause the plaque ulcer of PAU.

A 65-year-old woman presented with syncope after having breakfast. She reported dizziness and blackout like symptoms before the syncope episode; however, the neurologic examination showed no evidence of hemiplegia or other neurologic residue. The brain computed tomography (CT scan) revealed no evidence of intracranial hemorrhage or stroke lesion. The patient collapsed with presentation of shock and altered consciousness 2 h after arriving at the emergency department. The physical examination revealed hypotension and engorged jugular veins. Emergent wholebody CT scan was performed, and the noncontrast-enhanced CT scan showed a high attenuation crescent sign in the ascending aortic wall consistent with an intramural hematoma (IMH), and filling of the pericardium consistent with an intramural hemopericardium (Fig. 1a). Contrastenhanced CT scan demonstrated low attenuation of the ascending aortic wall and a penetrating atherosclerotic ulcer (PAU) in the aortic root (Fig. 1b). The patient received emergent ascending aorta grafting surgery. The postoperative period was uneventful, and the patient recovered well. IMH with PAU of aorta are included in the acute aortic syndromes as aortic dissection variants. IMH and aortic dissection share similar risk factors, and are classified the same way as Stanford type A and type B. Ascending aorta IMH may cause aortic regurgitation, hemopericardium or aortic rupture. Predictors of adverse outcomes include syncope, enlarged aorta diameter ([55 mm) and increased hematoma thickness ([16 mm) [1]. PAU often has a variable degree of IMH. Patients with type A IMH with PAU should have early surgery, if possible, since they are at high risk for dissection, rupture, aortic regurgitation, cardiac tamponade, or myocardial infarction. PAU accounts for 2–7 % of symptomatic patients with suspected acute aortic syndrome, and an IMH can be identified in approximately 6 % of aortic dissections [2, 3]. Noncontrast enhanced CT scan with a high attenuation crescent sign

For intramural hematoma and penetrating atherosclerotic ulcer, long-term behavior and treatment are controversial. This study evaluates the long-term behavior of intramural hematoma and penetrating atherosclerotic ulcer, including radiologic follow-up and survival analysis.Between 1995 and 2014, 108 patients (mean age, 70.8 ± 10 years; 56% female) presented with intramural hematoma or penetrating atherosclerotic ulcer to Yale-New Haven Hospital (New Haven, Conn). We reviewed the medical records, radiology, and online mortality databases.Ten of 55 patients (18%) with intramural hematoma and 17 of 53 patients (32%) with penetrating atherosclerotic ulcer had rupture state symptoms on admission, both greater than type A (8%) or type B dissection (4%) (P.001). No branch vascular occlusion occurred. For patients with intramural hematoma with follow-up imaging, 8 of 14 (57%) worsened (mean follow-up, 9.4 months) and 6 (43%) underwent late surgery. For patients with penetrating atherosclerotic ulcer with follow-up imaging, 6 of 20 (30%) worsened and underwent late surgery, and 11 (55%) showed no change (mean follow-up, 34.3 months). Overall survivals were 77%, 70%, 58%, and 33% at 1, 3, 5, and 10 years, respectively. No operative deaths occurred for patients with nonrupture state. Patients with penetrating atherosclerotic ulcer with initial surgical treatment had better long-term survival than patients treated medically (P = .037). In the intramural hematoma group, no such difference was observed (P = .10).At presentation, the incidence of early rupture of intramural hematoma and penetrating atherosclerotic ulcer was higher than for typical dissection. For branch vessels, intramural hematoma never occludes branch arteries. On imaging follow-up, patients with intramural hematoma and penetrating atherosclerotic ulcer rarely improved, with late surgery commonly needed. Better survival was observed for the initial surgical management of patients with penetrating atherosclerotic ulcer compared with initial medical management.

The term acute aortic syndrome comprises aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. The most recent developments in acute aortic syndromes include (1) a change in the mindset that each entity is pathologically distinct, with a shift toward considering the acute aortic syndromes as points along a spectrum of aortic disease, (2) the optimization of aortic imaging quality and radiation dose, and (3) surgical or endovascular management. This review article focuses on how these developments pertain to thoracic radiologists.

An expert panel on the treatment of type B intramural haematoma (IMH) and penetrating atherosclerotic ulcer (PAU) consisting of cardiologists, cardiothoracic surgeons, vascular surgeons and interventional radiologists reviewed the literature to develop treatment algorithms using a consensus method. Data from 46 studies considered relevant were retrieved for a total of 1386 patients consisting of 925 with IMH, and 461 with PAU. The weighted mean 30-day mortality from IMH was 3.9%, 3-year aortic event-related mortality with medical treatment 5.4%, open surgery 23.2% and endovascular therapy 7.1%. In patients with PAU early and 3-year aortic event-mortality rates with open surgery were 15.9 and 25.0%, respectively, and with TEVAR were 7.2 and 10.4%, respectively. According to panel consensus statements, haemodynamic instability, persistent pain, signs of impending rupture and progressive periaortic haemorrhage in two successive imaging studies require immediate surgical or endovascular treatment. In the absence of these complications, medical treatment is warranted, with imaging control at 7 days, 3 and 6 months and annually thereafter. In the chronic phase, aortic diameter >55 mm or a yearly increase ≥ 5 mm should be considered indications for open surgery or thoracic endovascular treatment, with the latter being preferred. In complicated type B aortic PAU and IMH, endovascular repair is the best treatment option in the presence of suitable anatomy.

Background Type A intramural hematoma (IMH) has two different etiologies, which are rupture of vasa vasorum and penetrating atherosclerotic ulcer (PAU); however, it is difficult to know which is the initiating event. Methods Between January 1993 and August 2004, 28 patients of acute type A IMH were treated in our department and were divided into two groups, 20 patients with IMH probably caused by rupture of vasa vasorum (non-PAU group) and 8 patients with IMH probably caused by PAU (PAU group), according to pathologic specimen and atherosclerotic findings on computed tomography. Background factors, radiographic findings, and prognosis were analyzed retrospectively. Results Surgery was performed in 15 patients (75%) in non–PAU group and 4 patients (50%) in PAU group during the first admission. Late progression was noted in 3 patients, and operation was required. Finally, operation was performed in 22 patients (78.6%). The history of myocardial infarction ( p = 0.026) and chronic renal failure ( p = 0.026) were more associated with PAU group than with non-PAU group. Ascending aortic diameter at the onset was significantly larger in non-PAU group (50.3 ± 6.6 mm) than in PAU group (43.9 ± 9.0 mm; p = 0.046), and there were significantly more ulcer lesions in PAU group (1.9 ± 0.4) than in non-PAU group (1.1 ± 0.4; p = 0.0004). There was no significant difference in long-term survival rates between them. Conclusions The PAU group patients have more coexisting atherosclerotic diseases and multiple aortic ulcer lesions with significantly mild ascending aortic dilatation compared with non-PAU group patients.

A 72-year-old man was admitted to our hospital for acute back pain. Transesophageal echocardiography (TEE), computed tomography (CT) and magnetic resonance imaging (MRI) all showed the presence of intramural hematoma (IMH) located in the descending aorta, with bilateral pleural effusions. The patient was initially referred for medical therapy and 'watchful waiting'. However, he continued to have back pain, so we decided to perform invasive aortography examination and intra-aortic ultrasound (IAU) imaging. No penetrating aortic ulcer (PAU) was found on multiple angiographic views, but intra-aorta ultrasound imaging clearly showed a PAU measuring 3x1 mm(2) in connection with the intramural hematoma. Even retrospective analysis of CT images failed to reveal this PAU. Therefore, we think that IAU imaging may be a useful tool in the diagnosis of PAU.

A 59-year-old man showed a saccular aneurysm due to a penetrating atherosclerotic ulcer, as well as a small type B aortic dissection located in the proximal descending aorta. The lesion was treated by the implantation of a stent-graft. On release, the stent-graft dislocated into the aortic arch. Intraoperative angiogram showed free perfusion of the brachiocephalic trunk and left common carotid artery; however, an overstenting of the carotid artery was apparent. Computed tomographic scan exhibited a complete covering of the supra-aortic vessels, and conventional, open aortic arch surgery was inevitable. A partial resection of the proximal part of the stent-graft was performed.

INTRODUCTION Endovascular therapy is being used increasingly also to treat ruptured infrarenal aortic aneurysms. Non-traumatic rupture of non-aneurysmatic infrarenal aorta is an absolute rarity. METHODS The feasibility of endovascular repair of infrarenal aortic rupture is demonstrated with a case history and a literature review. RESULTS A 58-year-old male developed spontaneous rupture of his infrarenal aorta after successful chemotherapy resulting in regression of a periaortic tumor. The patient suffered from a sepsis for several days before aortic rupture was discovered during computed tomography for focus search. Immediate endovascular stent-graft repair was performed under emergency conditions. There is no recurrence and the patient is doing well with the stent-graft in place without any pathological finding after a follow-up of 24 months. So far only three further cases have been reported of endovascular repair for penetrating atherosclerotic ulcer with rupture of the infrarenal aorta. DISCUSSION This is the first report of endovascular repair of aortic rupture due to successful chemotherapy of a periaortic mesothelioma. Furthermore, this is the fourth case of successful stent-graft placement to treat non-aneurysmatic rupture of the infrarenal aorta. Minimally invasive endovascular therapy should become a standard treatment option for aortic rupture.

Acute aortic syndromes (AAS) encompass a spectrum of emergencies. These include those non-traumatic disease entities of the aorta namely, penetrating atherosclerotic ulcer, intramural haematoma, dissection and aneurysm rupture. The various types of AAS cannot be reliably differentiated on clinical grounds alone. Acute thoracic aortic injury is usually included in this group even though clinical presentation is different, i.e., in the context of trauma, the imaging features are very similar. Differentiation of AAS from acute coronary syndrome (ACS) is important, however, it must be remembered that ACS may occur as a result of AAS. Now electrocardiogram (ECG)-gating technology is widely available, ECG-gated multi-detector row computed tomography (MDCT) is a powerful clinical tool in the acute emergency setting, which enables rapid and specific diagnosis of aortic pathology. ECG-gated MDCT significantly reduces motion artefact, avoids potential pitfalls in diagnosis and often provides diagnostic information about the coronary arteries. It should be used as a first-line imaging technique. This article examines the role of MDCT imaging and cardiac gating in the assessment of AAS and discusses the differentiation of this spectrum of aortic diseases with reference to the key imaging findings as obtained by experience in our institution.

Recent advancement of MDCT provides high-resolution axial images with optimal contrast enhancement and 3D reformatted images of the thoracic aorta. MDCT is now playing a dominant and critical role in the evaluation of thoracic aortic disease. This article will focus on procedural considerations of MDCT: acquisition parameters, contrast injection and post-processing techniques and imaging findings of thoracic aortic diseases including, aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, aneurysm, and traumatic injury.

Introduction and objectives The purpose of this study was to evaluate the experience of a multidisciplinary team in the percutaneous treatment of thoracic aorta disease. Patients and Method Between December 2001 and January 2004, 15 patients were selected for percutaneous treatment at the Thoracic Aorta Unit of the Hospital Universitario Central de Asturias. The motives for stent implantation were: degenerative aneurysm (n=7), acute dissection (n=4), penetrating atherosclerotic ulcer (n=1), posttrauma-tic aneurysm (n=2), and postsurgery pseudoaneurysm (n=1). Four procedures were considered emergencies. Another 2 patients underwent prior surgery of the supra-aortic branches. Previous computed tomographic angiography and arteriography were performed, and in complex cases of dissection, magnetic resonance imaging was used. All stent placement procedures were performed in the hemodynamics laboratory. All patients underwent computed tomographic angiography during follow-up. Results Stent positioning was technically successful in 14 patients. The mean length of aortic coverage was 230 ±110 mm (range, 110-440 mm). No intraoperative deaths occurred. There was one in-hospital death. Transient postimplantation syndrome was presented in 3 patients. Two type I endoleaks, 1 type II endoleak and 1 thrombosis of the superior mesenteric artery were found on computed tomographic angiography at 1 month. 1 type III endoleak and one type II endoleak were found during subsequent follow-up. Conclusions Endovascular stent-grafting is a valid alternative in the treatment of aortic disease in high-risk patients. Coordination between different medical specialties and appropriate selection of patients are needed. Long-term follow-up is necessary to ensure the usefulness and efficacy of the procedure.

A 71-year-old woman presented with acute chest pain and was admitted at our institution. Computed tomography revealed a penetrating atherosclerotic ulcer in the ascending aorta with extensive intramural hematoma. A transapical endovascular stenting was successfully performed. Computed tomography at a 6-month follow-up visit revealed a type I endoleak, which was restented through the same approach. Despite initial satisfactory results, follow-up revealed a persistent endoleak, so that a high-risk open surgical repair was required. Surgical replacement of the ascending aorta was successfully performed without postoperative neurologic deficit.

A 57-year-old man was admitted to our department with recent onset of chest pain. Computed tomography (CT) scans revealed an acute aortic syndrome manifested by a penetrating atherosclerotic ulcer and contained rupture at the level of origin of an aberrant right subclavian artery. A combined vascular and endovascular approach was selected. The entire arch was rerouted, a reversed bifurcated Dacron prosthesis was placed, and a bypass was created between the right common carotid artery and the lusorian artery, followed by thoracic endovascular aortic repair. The clinical course was uneventful. The CT scan obtained after the procedure revealed regular supra-aortic perfusion and complete exclusion of the complex lesion.

•. Acute aortic syndrome comprises three interrelated pathologies: intramural haematoma, penetrating atherosclerotic ulcer and aortic dissection. •. Multislice CT is the imaging modality of choice. •. A pre-contrast scan significantly aids the detection of intramural haematoma. •. Intramural haematoma needs repeated imaging follow-up and can progress to penetrating atherosclerotic ulcer, pseudoaneurysm or dissection. •. In aortic dissection the false lumen is usually larger and may contain aortic “cobwebs”. The term “acute aortic syndrome” (AAS) encompasses a spectrum of aortic emergencies, which include aortic dissection, intramural haematoma (IMH) and penetrating atherosclerotic ulcer (PAU). Some authors have also included ruptured aneurysms and aortic transection in this group; however, we will confine our discussion to the original definition by Vilacosta, (Vilacosta I, San Roman JA. Acute aortic syndrome. Heart 2001;85:365–8) [1]. The clinical signs and symptoms of these entities are similar and...

ObjectiveThe clinical behavior of penetrating atherosclerotic ulcers of the aorta is controversial. We reviewed our experience with this entity over a 25-year interval.MethodsCases were identified using the Department of Radiology database searching for the diagnoses of aortic dissection, intramural hematoma, or penetrating ulcer between 1977 and 2002. Available imaging studies were reviewed by a vascular radiologist to confirm the diagnosis of penetrating ulcer and perform serial measurements.ResultsOne hundred five patients with penetrating atherosclerotic ulcers of the descending thoracic aorta or arch with (n = 85) or without (n = 20) associated intramural hematoma were confirmed. Two patients with ulcers in the ascending aorta were excluded. There were 73 men and 32 women with a mean age of 72 ± 9 years. Comorbidities included hypertension in 97 (92%), tobacco use in 81 (77%), and coronary artery disease in 48 (46%). Of nonoperated patients with follow-up studies, the mean thickness of the intramural hematoma decreased at 1 month in 89% and completely resolved at 1 year in 85%. There were 3 deaths (4%) within 30 days among 76 patients treated medically and 6 deaths (21%) among 29 patients treated surgically (P < .05). Failure of medical therapy defined as surgery or death was predicted by rupture at presentation (odds ratio = 20.6) and era of treatment (before 1990, odds ratio 9.9) but not aortic diameter, ulcer size, or extent of hematoma.ConclusionAlthough careful follow-up is necessary, many penetrating atherosclerotic ulcers of the thoracic aorta can be managed nonoperatively in the acute setting.

Penetrating atherosclerotic ulcer (PAU)によると考えられる腎動脈下腹部大動脈の破裂症例を経験した.症例は68歳男性.腹痛を主訴に来院しCT検査中にショック状態となった.造影CTにてほぼ正常径の腹部大動脈に接して巨大な後腹膜血腫を認めた.血腫は大動脈と交通し造影剤の流入を認め,大動脈破裂と診断し緊急手術を施行した.術中,腎動脈下大動脈左側に直径約1.5cmの破裂孔を認めた.近傍の大動脈に拡張変化は認めなかった.人工血管置換術を施行したが術後2日目に循環不全にて失った.病理組織は得られていないがCTおよび術中の肉眼所見よりPAUが原因と考えられる大動脈破裂と診断した.

Aortic aneurysm rupture, aortic dissection, penetrating atherosclerotic ulcer, acute aortic occlusion, traumatic aortic injury, and aortic fistula represent acute abdominal aortic conditions. Because of its speed and proximity to the emergency department, helical CT is the imaging test of choice for these conditions. MR imaging also plays an important role in the imaging of aortic dissection and penetrating atherosclerotic ulcer. Ultrasound is helpful when CT is not readily available and the patient is unable or too unstable to undergo MR imaging. Because CT is the dominant imaging method for diagnosing acute abdominal aortic conditions, this article focuses on CT techniques and manifestations of this group of acute abdominal disorders.

Purpose of the review To summarize the current clinical experience with endovascular stent-graft repair in patients presenting with penetrating atherosclerotic ulcer of the descending thoracic aorta. Recent findings Penetrating atherosclerotic ulcer is increasingly acknowledged as a pathologic variant of classic false lumen aortic dissection with a high incidence of bleeding complications and rupture in up to 40% of patients. So far, no generally accepted therapeutic regimen has been established, as the natural history of penetrating atherosclerotic ulcer is not yet fully understood. Recently, however, penetrating atherosclerotic ulcer is increasingly considered to be treated more aggressively (preferentially surgically). Given the high morbidity and mortality of aortic surgery, endovascular stent-graft repair may be an attractive, less invasive alternative in selected patients with penetrating atherosclerotic ulcer. Sealing of a penetrating ulcer by the stent-graft reduces wall stress and thus provides stabilization of the diseased aortic segment. Summary To date, there is limited experience with endovascular repair in penetrating atherosclerotic ulcer, suggesting that endovascular stent-graft repair is safe and effective. Long-term results are, however, required to fully establish the efficacy of endovascular repair in penetrating atherosclerotic ulcer.

Thoracic aortic dissection is the most frequent cause of aortic emergency, and unless it is rapidly diagnosed and treated, the result is death. Helical computed tomography (CT) permits the diagnosis of acute aortic dissection with a sensitivity and specificity of nearly 100%. This imaging modality also enables differentiation between proximal aortic dissection (type A in the Stanford classification) and distal aortic dissection (Stanford type B), which are treated differently and have different prognoses. In 70% of patients in whom nontraumatic acute thoracic aortic dissection is diagnosed after evaluation with helical CT, scans show the typical signs of aortic dissection, with rupture and displacement of the intima. CT also can depict other pathologic entities with similar clinical manifestations, such as intramural hematoma and penetrating atherosclerotic ulcer. Awareness of the different radiologic appearances of these disease entities is essential for differential diagnosis. More than one-third of patients with aortic dissection show signs and symptoms indicative of systemic involvement. Because branch-vessel involvement may increase morbidity and mortality, in this group of patients it is important to evaluate the entire aorta so as to determine the distal extent of the dissection and detect any systemic involvement.

Objective: To report our experience with endovascular stentgraft repair of diseases of the descending thoracic aorta in high risk patients. Methods: Twenty-one procedures were performed in 20 patients (10 women), aged 22 – 81 years, for disease of the descending thoracic aorta with the Gore Excluder thoracic endoprosthesise (WL Gore) ðn ¼ 11Þ and the Talent LPS Stent Graft System (Medtronic AVE) ðn ¼ 10Þ. All patients were considered high operative risk. Diagnoses included saccular aneurysm, aneurysm rupture, mycotic aneurysm, penetrating atherosclerotic ulcer, aortic dissection and aortitis. The access vessels were a tube graft of the (thoraco-) abdominal aorta ðn ¼ 4Þ, the common iliac ðn ¼ 6Þ and the common femoral artery ðn ¼ 11Þ. Several patients needed major cardiovascular surgery for concomitant disease during the same stay. Computed tomography scan and chest X-ray was performed at 3 and 6 months and thereafter every sixth month postoperatively. Results: Two patients died. One had a colon perforation 8 days postoperatively and died after 3.5 months, and the other with preoperative sepsis and a mycotic aneurysm died on day 11 from cardiac and renal failure. In one patient the stentgraft dislocated during release, and an additional stentgraft had to be implanted 1 week later to treat the proximal leak. In another patient the stentgraft could not be released from the introducer, and was pulled back to the aortic bifurcation and retrieved through laparotomy. Eighteen patients have been followed for 1 – 24 months, and no migration, wire fractures or endoleak have been seen. There were no neurologic complications. One patient treated for infected pseudoaneurysm had a chronic graft infection. Conclusion: In this small number of patients with high operative risk, short-term results of endovascular stentgraft repair of variable diseases of the descending aorta have been satisfactory. Stentgraft repair could be a valuable supplement to surgery for patients with complex multilevel or multiorgan disease. q 2003 Elsevier B.V. All rights reserved.

We report a case of mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer (PAU). An 81-year-old woman was admitted to a local hospital with fever and abdominal pain, and when her symptoms were not improved by antibiotics, she was referred to our department. Computed tomography (CT) and angiography showed a saccular aneurysm below the renal arteries, and an emergency laparotomy was performed because we suspected a mycotic abdominal aortic pseudoaneurysm. An abscess was found on the proximal side of the jejunum, caused by an aneurysm penetrating the serosa. We diagnosed a mycotic pseudoaneurysm after finding the anterior wall of the aorta penetrated by intense calcification. The pseudoaneurysm was resected with the abscess and the area was covered with a pedicled omental flap to prevent infection. An axillofemoral bypass was also done. The patient recovered well.

Acute aortic syndromes refer to the spectrum of aortic emergencies that include nontraumatic diseases of the aorta, such as aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, aortic aneurysm leak, as well as traumatic aortic transection. Patients presenting with nontraumatic acute aortic syndromes usually have a similar clinical profile; hence, clinical diagnosis is difficult. Computed tomography (CT) and magnetic resonance imaging (MRI) allow for specific diagnosis of the underlying condition. Traumatic rupture of the aorta is one of the most dreaded complications of blunt chest trauma; therefore, in patients with high-risk deceleration injuries, radiographic assessment of the aorta is crucial. Imaging methods should detect even subtle aortic wall disruption and should provide a mechanism for communicating the findings to the surgical team. Noninvasive, cross-sectional imaging techniques have proven efficacy in the diagnosis of aortic pathology and have largely replaced aortography. Both CT and MR imaging provide aortogram-like reconstruction of the original data sets, and in addition to assessing the aortic lumen, permit detailed evaluation of the aortic wall, as well as comprehensive assessment of thoracic and abdominal viscera. This article addresses the role of different imaging modalities in assessment of acute aortic syndromes, with focus on CT and MRI, and with discussion of the key imaging findings that allow distinction among the various aortic pathologies.

Aorto-esophageal fistula (AEF) is a rare and life threatening condition, which can be rapidly fatal. More than half of such cases are secondary to aortic aneurysm rupture. There are only two previous reports describing AEF caused by penetrating atherosclerotic ulcer. We present multidetector computed tomography findings in a case of AEF secondary to penetrating atherosclerotic ulcer.

The purpose of this study was to evaluate clinical feasibility and immediate outcome of stent-graft repair of the thoracic aorta. From December 1999 to January 2001, a total of 14 patients underwent stent-graft repair of the thoracic aorta. The underlying etiologies were traumatic rupture of the aortic isthmus in four cases, Stanford type B dissection in four, thoracic aortic aneurysm in three, penetrating atherosclerotic ulcer in two cases, and postoperative aortoesophageal fistula in one case. Stent-graft placement was performed under angiographic control in all cases in association with transesophageal echography in seven cases. The procedure was performed under emergency conditions in five cases. Thirteen patients presented contraindications for surgery. Stent-graft placement was successful in all cases. No further surgery has been performed in any case. Thus we conclude that endovascular treatment of the thoracic aorta using stent grafts is a promising therapeutic modality in patients with contraindications for conventional surgical treatment.

Penetrating atherosclerotic ulcer (PAU) is most often found in the descending aorta but rarely in the ascending aorta. In such a rare case, a 63-year-old man with ischemic change at precordial leads in electrocardiography was found in coronary angiography to have the left main trunk stenosis and in aortography (aortic phase of left ventriculography) to have PAU in the ascending aorta. We conducted 3-vessel coronary artery bypass grafting and replaced the ascending aorta. Preoperative evaluation of the ascending aorta is thus important in cardiac surgery as in this case.

Background — Advances in imaging techniques have increased the recognition of aortic intramural hematomas (IMHs) and penetrating atherosclerotic ulcers (PAUs); however, distinction between IMH and PAU remains unclear. We intended to clarify differences between IMH coexisting with PAU and IMH not associated with PAU by comparisons of clinical features, imaging findings, and patient outcome to derive the optimal therapeutic approach. Methods and Results — We performed a retrospective analysis of 65 symptomatic patients with aortic IMH. There were 34 patients with IMH associated with PAU (group 1) and 31 patients with IMH unaccompanied by PAU (group 2). Involvement of the ascending aorta (type A) was more frequent in group 2 (8 of 31, 26%), whereas most of the patients in group 1 had exclusive involvement of the descending aorta (type B) (31of 34, 91%). Patients were subdivided into 2 categories, those with clinical progression and those with stable disease. Forty-eight percent of patients in group 1 and 8% in group 2 were in the progressive category ( P =0.002). Clinical and radiological findings were compared between those group 1 patients who had a progressive disease course (n=12) and those who were stable (n=13). Sustained or recurrent pain ( P P =0.0003), and both the maximum diameter ( P =0.004) and maximum depth ( P =0.003) of the PAU were reliable predictors of disease progression. Conclusions — This study suggests a difference in disease behavior that argues for the prognostic importance of making a clear distinction between IMH caused by PAU and IMH not associated with PAU. IMH with PAU was significantly associated with a progressive disease course, whereas IMH without PAU typically had a stable course, especially when limited to the descending thoracic aorta.

Objective: Most studies on variant forms of aortic dissection—penetrating ulcer and intramural hematoma—have focused on the initial presenting episode, with scant follow-up. This investigation provides midterm follow-up of penetrating ulcer and intramural hematoma to determine whether the aorta shows healing according to radiography, goes on to dilate, or tends to rupture during later follow-up. Methods: Forty-five patients with penetrating ulcers (n = 26) or intramural hematomas (n = 19) were treated at our institution. Ten patients with penetrating ulcers were male and 16 were female, and their ages ranged from 54 to 87 years (mean 72 years). Eight patients with intramural hematomas were male and 11 were female, and their ages ranged from 54 to 88 years (mean 74 years). These patients all had symptoms of aortic disease. Patients with incidental imaging findings were not considered. Results: In the group with penetrating ulcers, rupture occurred during the initial admission in 10 (38%) cases, 17 patients (65%) underwent surgery, and 22 patients (85%) survived to hospital discharge. Among those with intramural hematomas, rupture occurred during the initial admission in 5 cases (26%), 7 patients (37%) underwent surgery, and 16 patients (84%) survived to hospital discharge. Follow-up ranged from 1 month to 12.5 years (mean 3.4 years). No ischemic vascular complications occurred. Imaging follow-up was available for 26 of the 45 patients. Of these, 19% of lesions showed resolution, 23% had worsened, 39% had progressed to typical dissection, and 19% were unchanged. Six late deaths were known to be caused by rupture. In the group with penetrating ulcers, aortic diameter increased from 4.8 to 5.1 cm during the course of 14 months. In the group with intramural hematomas, aortic diameter increased from 5.3 to 5.9 cm during the course of 21 months. Overall survivals were 80% at 1 year, 73% at 3 years, and 66% at 5 years. Conclusions: Intramural hematoma and penetrating ulcer are lesions associated with advanced age. Women predominate. Penetrating ulcer and intramural hematoma rupture both early and late. Radiographically documented worsening, improvement, or frank dissection may occur with time. Aortic growth does occur (0.2 cm per year for penetrating ulcer and 0.4 cm per year for intramural hematoma). Vascular ischemic complications do not occur. Because of the high early rupture rate, the frequency of radiographic worsening, and the documented occurrence of late rupture, we now recommend surgical replacement of the aorta for these virulent vascular lesions as long as the patient's comorbidities do not preclude surgical intervention. J Thorac Cardiovasc Surg 2002;123:1051-9

Penetrating atherosclerotic ulcer (PAU) is defined as an atherosclerotic lesion in which an ulceration occurs in the diseased aortic intima leading to disruption of the internal elastic lamina. It may cause a pseudoaneurysm formation or transmural aortic rupture. We describe a patient in whom a ruptured PAU in the distal aortic arch was treated successfully by a surgical endovascular stent graft. Through a median sternotomy and under deep hypothermic circulatory arrest, the aorta was transected between the left common carotid and subclavian arteries. A dacron prosthetic graft with self-expanding original Z type stents attached inside of the distal half was inserted through the aortotomy to exclude the PAU. By performing the procedure through a median sternotomy, we could eliminate dissection around the ruptured aortic wall. The stented graft was secured safely in the thoracic aorta to exclude the ruptured ulceration located distal to the left subclavian artery. PAU should be recognized widely as a distinct cardiovascular surgical problem which may lead to intramural hematoma with or without dissection or rupture.

Isolated saccular compared to fusiform aneurysm is considered to be a rare entity with challenges of its own. A 62-year-old female was diagnosed with a case of saccular aneurysm and penetrating atherosclerotic ulcer of the aortic arch. Additionally, she also had one vessel coronary artery disease and type B abdominal aortic dissection. She was then managed with open aortic arch repair and coronary artery bypass grafting. If required, elective endovascular repair will be done for the abdominal aorta on a later date.

Pulmonary artery involvement has been reported in various degrees of complicated dissection of the ascending aorta. The prognosis remains poor without high-risk surgical intervention, but conservative management can be considered in high-risk cases. We report a case of nonoperative management of an octogenarian who presented with a contained rupture of his proximal ascending aorta, likely from a penetrating atherosclerotic ulcer. It was complicated by extrinsic compression of the pulmonary trunk and transient pulmonary hypertension without features of acute right heart failure. He remained alive at the one-year follow-up.

A 69-year-old man presented with chest pain and a computed tomography scan demonstrated an acute penetrating atherosclerotic ulcer (PAU) of the proximal descending aorta with an associated intramural hematoma (IMH) extending retrograde to the aortic root and distally to the renal arteries. He successfully underwent endovascular repair of the PAU and medical management of the associated ascending intramural hematoma with complete resolution at 6 months.

Thoracic aortic emergencies account for 10% of thoracic-related admissions in the United States and remain associated with high morbidity and mortality rates. Open repair has declined owing to the emergence of thoracic endovascular aortic repair (TEVAR), but data on emergency TEVAR use for acute aortic pathology remain limited. We therefore reviewed our experience.We retrospectively evaluated emergency descending thoracic aortic endovascular interventions performed at a single academic level 1 trauma center between January 2005 and August 2013 including all cases of traumatic aortic injury, ruptured descending thoracic aneurysm, penetrating atherosclerotic ulcer, aortoenteric fistula, and acute complicated type B dissection. Demographics, clinical data, and outcomes were extracted. Stepwise logistic regression was used to identify independent risk factors for death.During the study period, 51 patients underwent TEVAR; 22 cases (43.1%) were performed emergently (11 patients [50.0%] traumatic aortic injury; 4 [18.2%] ruptured descending thoracic aneurysm; 4 [18.2%] complicated type B dissection; 2 [9.1%] penetrating aortic ulcer; and 1 [4.5%] aortoenteric fistula). Overall, 72.7% (n = 16) were male with a mean age of 54.8 ± 15.9 years. Nineteen patients (86.4%) required only a single TEVAR procedure, whereas 2 (9.1%) required additional endovascular therapy, and 1 (4.5%) open thoracotomy. Four traumatic aortic injury patients required exploratory laparotomy for concomitant intra-abdominal injuries. During a mean hospital length of stay of 18.9 days (range, 1 to 76 days), 3 patients (13.6%) developed major complications. In-hospital mortality was 27.2%, consisting of 6 deaths from traumatic brain injury (1); exsanguination in the operating room before repair could be achieved (2); bowel ischemia (1) and multisystem organ failure (1); and family withdrawal of care (1). A stepwise logistic regression model identified 24-hour packed red blood cell requirements ≥4 units, admission mean arterial pressure60 mm Hg, and 24-hour fresh frozen plasma to packed red blood cell (pRBC) ratio1:1.5 as independent risk factors for death in this cohort. During a mean follow-up of 369 days (range, 35 to 957 days), no subsequent major complications or deaths occurred. All patients underwent serial computed tomographic angiography surveillance, and no device-related problems were identified during intermediate follow-up.Thoracic aortic emergencies remain challenging. Our experience in a moderate-volume center supports the utilization of TEVAR in the acute setting. Twenty-four-hour pRBC requirements ≥4 units, admission mean arterial pressure60 mm Hg, and 24 hour fresh frozen plasma to pRBC ratio1:1.5 were independently associated with death.

Acute aortic syndrome (AAS) is a term that describes interrelated aortic emergencies with similar clinical characteristics and challenges. These are aortic dissection (AD), intramural hematoma (IH), and penetrating atherosclerotic ulcer (PAU). The incidence of AAS is three cases per 100.000 persons per year. Diverse genetic disorders and acquired conditions have been related to the pathogenesis of this disease. Clinical features of patients with any of the three conditions comprising AAS are very similar. A high degree of clinical suspicion and imaging studies are necessary for an accurate diagnosis. Prognosis is clearly related to underlying diagnosis and appropriate surgical repair, in the case of proximal involvement of the aorta. Involvement of distal segments of the aorta may require medical or endovascular therapy according to the presence of complications. After hospital discharge, patients require lifelong follow-up.

Dear Editor: Henn et al. [1] have nicely described a case scenario whereby a penetrating atherosclerotic ulcer (PAU) of the descending aorta extends with intramural hematoma (IMH) into the ascending aorta. For those of us who manage a lot of acute aortic pathology, this clinical scenario occurs not that infrequently. Based on the dictum that all type A pathology is treated first, the question is whether these patients should be managed by replacement of their ascending aorta first with subsequent repair of their PAU at a later date. Should the ascending be repaired and then insert an endograft distally in an open technique in the same setting? Or should we do as the authors have suggested: just treat the PAU with a covered stent endograft in the descending thoracic aorta? Surprisingly, there is little literature or data to help us manage this clinical scenario. In the present case report, the authors describe a case in which a stent graft was placed in the descending thoracic aorta with subsequent resolution of the ascending aortic IMH. I personally have done this before, as well, with mixed results. There are multiple questions that remain unresolved about this scenario (and others I am sure our readers have asked). For example, does one balloon the endovascular prosthesis that was used to treat the PAU? Is it safe to carry a wire over into the arch and ascending aorta? What is the risk of creating a true type A dissection in these patients? Finally, what are the criteria for a spinal drain in these cases? One might also ask the authors what was their plan, had the IMH in the ascending aorta progressed to a full blown dissection both acutely and chronically; a reverse elephant trunk with repair of the arch, or just repair of the ascending aorta? Does having a stent graft in place change the management of these complex patients and almost ensure that circulatory arrest is required to remove the stent graft placed for a PAU? I am reminded of two things in particular associated with this case, as the technical performance of an endograft in this position is not difficult. However, as a vascular surgeon, it would be imperative that I have a thorough discussion of this case with my cardiac surgery partners before taking a case like this one on (no matter how technically easy it is!). Second, I remember when Drs. Mike Deeb and Dave Williams at the University of Michigan started treating all of the type A dissection patients with malperfusion by fenestration and stenting first, prior to taking the patients to the operating room for their type A repair. At the time, this approach was believed to be heresy by some. Yet, they persevered and many patients were saved with renal, mesenteric, and spinal arteries perfused (i.e., few patients with dead gut, on dialysis, or paralyzed) with nearly identical improved mortality rates compared to those patients who were just taken straight to the operating room with malperfusion. It should give us all pause to think that maybe just treating the PAU in the present scenario was the right thing to do. Congratulations to the authors.

BackgroundIntramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and aortic dissection comprise a spectrum of acute aortic pathologies. Although thoracic endovascular aortic repair (TEVAR) has increasingly been applied to aortic dissection, there is a paucity of data on the anatomic effect of TEVAR for IMH. Our goal was to investigate the extent of aortic remodeling after TEVAR.MethodsA retrospective chart review from 2006 to 2012 was conducted on patients who underwent TEVAR for IMH. Data were collected from the electronic medical record. Radiology images were reviewed and primary data points included diameter (TLD) and volume measurements for aortic true lumen and total aortic diameter (TAD) and volume at the site of maximal pathology. Aortic remodeling was evidenced by a TAD/TLD ratio closest to 1.0. Patients with no imaging beyond 30 days postoperatively were excluded.ResultsDuring the 6-year period, 44 patients underwent TEVAR for IMH. Twenty-five patients had an IMH with concomitant PAU. There were 25 (57%) female patients. Mean age was 71 ± 11 years, and 40 (91%) patients had hypertension. Operative indications included intractable pain in 31 (70%), rapidly progressing IMH or conversion to dissection in 13 (30%), rupture in 10 (23%), and uncontrolled hypertension in 6 (14%). Technically successful TEVAR was performed in all patients with 42 (95%) reporting complete relief of symptoms. The 30-day mortality rate was 5% with a 5% rate of permanent paraplegia or paraparesis. At a mean follow-up of 26 months, there were no additional aortic-related deaths and overall survival was 80% with a reintervention rate of 11%. For our imaging analysis, 10 patients were excluded because of lack of follow-up imaging beyond 30 days. At a mean follow-up of 13 months, all measured data points were statistically improved from before to after TEVAR: thickness of IMH (12 mm vs 4 mm; P = .01), mean TLD (35 mm vs 37 mm; P = .04), mean TAD (47 mm vs 42 mm; P = .02), TAD/TLD ratio (1.35 vs 1.14; P < .01), and IMH volume (103 cm3 vs 14 cm3; P < .01). The mean Δ in TAD/TLD ratio from before to after TEVAR for the reintervention group was Δ0.14, and the mean Δ in TAD/TLD ratio for the nonreintervention group was Δ0.29 (P = .05). Analysis of patients with isolated IMH and those with concomitant PAU revealed no statistical differences.ConclusionsTEVAR is safe and effective in treating IMH and based on longitudinal computed tomography scan analysis, aortic remodeling is evidenced by normalization of all measured indices.

Purpose: To describe a case of penetrating atherosclerotic ulcer of the aorta with a review of its natural history, diagnosis and management. Case Report: An elderly patient with a history of hypertension presented to the emergency room with the sudden onset of severe chest pain radiating to the back. The electrocardiogram showed left ventricular hypertrophy; the chest radiograph revealed mediastinal widening. Computed tomography was suspicious for a mediastinal hematoma without aortic dissection. Transesophageal echocardiography was also negative for dissection. An aortogram revealed a penetrating atherosclerotic ulcer of the descending thoracic aorta. The patient underwent successful resection and repair of the lesion. Conclusions: Penetrating atherosclerotic ulcer of the aorta is a potentially lethal lesion that must be promptly diagnosed and treated.

The pathogenesis of penetrating atherosclerotic ulcer (PAU) in aortic disease remains controversial. Between January 1995 and April 1999, five patients underwent treatment for a PAU in our hospital. All were men, ranging in age from 46 to 74 years, with a mean age of 66.2 years. The PAU was located on the thoracic descending aorta in three patients and on the abdominal aorta in two. Preoperative diagnosis was established by contrast-enhanced computed tomographic scan and aortogram. Surgery was performed in four patients, as graft replacement in three, and patch plasty in one. The remaining patient is being carefully observed on antihypertensive therapy. No connective tissue disorder, trauma, dissection, or infection was seen in any of the patients who underwent surgery, all of whom had uneventful postoperative courses with no perioperative complications or enlargement of the aorta. We conclude that surgical treatment should be performed for patients with PAU to prevent an aortic catastrophe caused by rapid development of the lesion. This report might provide further evidence of the importance of PAU.