Chapter 82 - Penetrating aortic ulcer

Question 1

Stanson 1986 on PAU

Answer 1

Defined it first as a distinct pathology

Question 2

PAU as a percentage of all acute aortic syndrome

Answer 2

2-3% only

Question 3

Definition of PAU

Answer 3

Focal ulcer at atheromatous plaque

Penetrates the internal elastic lamina

Question 4

What % is associated with atherosclerosis

Answer 4

53%

Question 5

What % has IMH also in the medial layer

Answer 5

80% (22-94%)

Question 6

Unlike dissections, PAU is not associated with these two things

Answer 6

1) genetic mutation

2) maximal points of hydraulic stress

Question 7

PAU characteristics epidemiology

Answer 7

1) 70-80 yr old
2) 2:1 M:F
3) HTN
4) smk, CAD, COPD

Question 8

PAU region in aorta and percentage

Answer 8

17% arch
68% descending
14% thoracoabdominal
4% infrarenal

Question 9

Symptomatic PAU rupture risk

Answer 9

9-44%

Question 10

PAU association with AAA, pleural effusion and hemothorax

Answer 10

AAA 40%
Pleural effusion 10-44%
Hemothorax 9.5%

Question 11

What’s more likely in causing emboli in PAU

Answer 11

Abdominal > thoracic PAU

Question 12

IMH size is usually limited in PAU to under this size

Answer 12

2.8 cm

Question 13

Rate of IMH thrombosis in PAU

Answer 13

85% thrombose in 1 year

Question 14

Prognosis in combination of PAU with IMH and AD

Answer 14

PAU + AD > PAU + IMH = PAU > AD alone > IMH alone

Question 15

Rate of AD in PAU

Answer 15

11-20% in thoracic aorta

Question 16

Dimension measurements of a PAU

Answer 16

Width = opening into the ulcer
Length = actual longitudinal extent of ulcer
Depth = the dept into the ulcer itself

Question 17

PAU diameter growth per year

Answer 17

0.2 cm/yr

Question 18

Treatment for incidental asymptomatic PAU

Answer 18

Non-operative

BP control

Question 19

Signs of PAU impending rupture

Answer 19

1) increase ulcer growth
2) periaortic hematoma
3) hemothorax
4) pleural effusion

Question 20

Treatment timeline for symptomatic PAU

Answer 20

Treat within 48 hours

Question 21

Radiographic signs that increase PAU rupture

Answer 21

1) Aortic diameter > 60 mm
2) PAU diameter > 20 mm
3) PAU depth > 20 mm

Question 22

Schumacker + King 1959 on PAU

Answer 22

First open repair of ruptured PAU in the descending aorta

Question 23

Open surgery mortality in PAU

Answer 23

5-21%

Question 24

Evidence on endovascular vs open repair in PAU

Answer 24

No RCT

Metaanalysis shows endo success 98.5% with clinical improvement 76-100%

Question 25

Endovascular treatment for PAU landing zone length

Answer 25

2 cm proximal and distal

Question 26

Oversizing in PAU

Answer 26

5-10%

Question 27

Ballooning endograft in PAU

Answer 27

Only seal zones and not at ulcer

Question 28

30d mortality following PAU repair

Answer 28

4.8% (0-26%)

Question 29

Morbidity post PAU repair

Answer 29

36.4%

Sepsis 1.2%
multiorgan failure 2.3%
renal failure 4%
pulmonary failure 4.7%
stroke 2.4%

Endo
Access complication 16%
endoleak 19%