A Case of Penetrating Atherosclerotic Ulcer Treated With Thoracic Endovascular Aortic Repair

Penetrating atherosclerotic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media.^1–3 PAU accounts for 2% to 7% of all acute aortic syndrome.⁴ PAU is at risk of intramural hematoma, pseudoaneurysm, aortic rupture, or an acute aortic dissection.⁵ Symptomatic PAU has to be assumed to indicate an emergency because the adventitia is reached and aortic rupture is expected.⁵ The rupture rate of symptomatic PAU has been reported to be as high as 45%.⁵ The main aim of the medical therapy in acute aortic syndrome is to reduce sheer stress on the diseased segment of the aorta by reducing blood pressure and cardiac contractility.^1,3 Systolic blood pressure should be lowered to 100 to 120 mm Hg. In the absence of contraindication, a β-blocker should be used.^1,3 Vasodilators may be required to achieve the target.^1,3 Thoracic endovascular aortic repair offers a less invasive approach in high-risk patients with PAU.^1,3

An 87-year-old woman was referred to our hospital with an 11-day history of continuous abdominal pain, left lower chest pain, and back pain. The patient had a history of hypertension and stable angina. Her medication consisted of an angiotensin-converting enzyme inhibitor and β-blocker. Antiplatelet was stopped after the development of chronic subdural hematoma 3 years before admission, and anticoagulation was not prescribed. Her physical examination was unremarkable except for a blood pressure of 158/103 mm Hg. Electrocardiography showed normal recordings. A contrast-enhanced chest computed tomography scan showed a narrow-necked, contrast-filled outpouching of the descending thoracic aorta (Figure 1). The dimensions of the ascending and descending aorta were normal. On the basis of these findings, PAU was suspected. She was admitted to the hospital, and a calcium channel blocker was added with resolution of symptoms within 1 day. Her systolic blood pressure was controlled below 120 mm Hg. A week later, she again developed significant back pain. Follow-up computed tomography revealed an expansion of the PAU and intramural hematoma (Figure 2). Urgent thoracic endovascular aortic repair with Gore CTAG 3110 was performed. Neither antiplatelet nor anticoagulation was prescribed after stent placement. Postoperative chest computed tomography showed resolution of the PAU and intramural hematoma (Figure 3). The patient subsequently recovered and was discharged uneventfully 14 days later.

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Figure 1.

Initial contrast-enhanced chest computed tomography shows a narrow-necked, contrast-filled outpouching of the descending thoracic aorta (arrow).

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Figure 2.

Follow-up contrast-enhanced chest computed tomography a week later shows an expansion of the penetrating atherosclerotic ulcer and intramural hematoma (arrow).

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Figure 3.

Postoperative chest computed tomography shows a resolution of the penetrating atherosclerotic ulcer and intramural hematoma (arrow).

• © 2015 American Heart Association, Inc.