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Thoracic Aortic Surgery Program, Divisions of Cardiothoracic and Vascular Surgery, Virginia Commonwealth University Medical Center, Medical College of Virginia Campus, West Hospital Building, 7th Floor, South Wing, 1200 E Broad St, PO Box 980068, Richmond VA 23298-0068
(Email: dbrinster{at}mcvh-vcu.edu).
This article by Botta and colleagues [1] documents the results of a single institutional experience in the treatment of penetrating atherosclerotic ulcers (PAUs) of the descending thoracic aorta with endovascular stent grafts in 19 patients. The technical success rate was stated as 18 of 19 cases (95%) and defined as successful insertion and deployment of the stent graft; however, there was 11% mortality from multisystem organ failure and also 3 patients (16%) with endoleaks. One patient required surgical treatment for correction of the endoleak, 1 patient required additional endografting, and 1 patient had spontaneous resolution. Late mortality was 4 of 17 (24%) in those patients surviving after 30 days, all from nonaortic causes, with the median follow-up period of 22 months. Therefore, there was an overall 32% mortality, including the two early deaths.
The risk of PAUs has been debated since their original description by Shennan in 1934. In 1986, Stanson and colleagues [2] presented data that suggested PAUs are a particularly malignant lesion with a high risk of perforation and dissection. On the basis of this data, emergency surgical therapy was advocated for all but the highest-risk candidates. In 1989, however, Hussain and colleagues [3] presented data that suggested the nature of PAUs was much more benign and that most lesions could be observed and medically managed. Those with free rupture and pleural effusions were designated for repair of the descending thoracic aorta.
In 1998, the Yale Thoracic Aortic Group published their experience with acute presentations of PAUs. The review of their results found that PAUs have an increased risk of rupture compared with classic aortic dissection. During medical observation, roughly 40% of PAUs progressed to rupture and required emergency surgery [4]. In 2002, the Yale group published their follow-up on an expanded series of patients. These additional results confirmed their original findings and found a 38% rupture rate of PAUs in the descending aorta. In addition, 14% of nonoperated on patients died from rupture of the PAU [5].
During the past decade, a number of articles have been published attempting to define a logical algorithm for the treatment of this lesion. These articles have focused on a number of factors, including acuity of presentation, severity and duration of back pain, presence of extravasation to suggest full thickness penetration of the lesion, aortic diameter expansion, depth and diameter of the ulceration in the aorta, and, most recently, treatment modality. The role of endovascular stent grafting for all acute aortic pathologies is currently being explored as experience with thoracic endovascular aortic repair is rapidly advancing.
Penetrating atherosclerotic ulcers have a unique irony in that the application of current stent grafts requires large-bore access sheaths or delivery systems (20F or larger). However, although PAUs are exceptionally suited for stent graft application owing to their limited longitudinal pathology, the patient population tends to be elderly with multiple associated comorbidities and a heavy systemic atherosclerotic burden that adversely affects direct access approaches to the common femoral arteries and may necessitate retroperitoneal exposure of the iliac vessels or inferior abdominal aorta.
This review by Botta and colleagues contributes to the expanding experience of endovascular aortic repair of PAUs in the descending thoracic aortic; however, the results of this study are concerning. Given that 16% of patients had documented endoleaks and, therefore, were ineffectively treated, does not provide confidence in endovascular repair for this pathology. In addition, the sum of in-hospital mortality and late term mortality was 32%, which does not differ significantly from medical treatment and observation for this lesion. Even provided that the four late deaths were nonaortic related, these results prompt the question of the appropriateness of this specialized intervention in this ill patient population given the rate of endoleaks and high mortality.
The application of thoracic endografting to treat these acute aortic pathologies is clearly evolving, and the ultimate effectiveness and durability of thoracic endografting remains to be determined as clinical experience increases. Although thoracic aortic stent grafting is a minimally invasive method to treat PAUs, the ultimate suitability and effectiveness remains to be determined by larger studies in this complex patient population. The work by Botta and colleagues continues to stimulate this interest in identifying the best treatment plan for a pathology that occurs is the most challenging and medically fragile patient population.
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