Chapter 82 - Penetrating aortic ulcer Flashcards
Stanson 1986 on PAU
Defined it first as a distinct pathology
PAU as a percentage of all acute aortic syndrome
2-3% only
Definition of PAU
Focal ulcer at atheromatous plaque
Penetrates the internal elastic lamina
What % is associated with atherosclerosis
53%
What % has IMH also in the medial layer
80% (22-94%)
Unlike dissections, PAU is not associated with these two things
1) genetic mutation
2) maximal points of hydraulic stress
PAU characteristics epidemiology
1) 70-80 yr old
2) 2:1 M:F
3) HTN
4) smk, CAD, COPD
PAU region in aorta and percentage
17% arch
68% descending
14% thoracoabdominal
4% infrarenal
Symptomatic PAU rupture risk
9-44%
PAU association with AAA, pleural effusion and hemothorax
AAA 40%
Pleural effusion 10-44%
Hemothorax 9.5%
What’s more likely in causing emboli in PAU
Abdominal > thoracic PAU
IMH size is usually limited in PAU to under this size
2.8 cm
Rate of IMH thrombosis in PAU
85% thrombose in 1 year
Prognosis in combination of PAU with IMH and AD
PAU + AD > PAU + IMH = PAU > AD alone > IMH alone
Rate of AD in PAU
11-20% in thoracic aorta
Dimension measurements of a PAU
Width = opening into the ulcer Length = actual longitudinal extent of ulcer Depth = the dept into the ulcer itself
PAU diameter growth per year
0.2 cm/yr
Treatment for incidental asymptomatic PAU
Non-operative
BP control
Signs of PAU impending rupture
1) increase ulcer growth
2) periaortic hematoma
3) hemothorax
4) pleural effusion
Treatment timeline for symptomatic PAU
Treat within 48 hours
Radiographic signs that increase PAU rupture
1) Aortic diameter > 60 mm
2) PAU diameter > 20 mm
3) PAU depth > 20 mm
Schumacker + King 1959 on PAU
First open repair of ruptured PAU in the descending aorta
Open surgery mortality in PAU
5-21%
Evidence on endovascular vs open repair in PAU
No RCT
Metaanalysis shows endo success 98.5% with clinical improvement 76-100%
Endovascular treatment for PAU landing zone length
2 cm proximal and distal
Oversizing in PAU
5-10%
Ballooning endograft in PAU
Only seal zones and not at ulcer
30d mortality following PAU repair
4.8% (0-26%)
Morbidity post PAU repair
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%
