Late Outcomes With Repair of Penetrating Thoracic Aortic Ulcers: The Merits of an Endovascular Approach Himanshu J. Patel, MD, Vikram Sood, BS, David.

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Late Outcomes With Repair of Penetrating Thoracic Aortic Ulcers: The Merits of an Endovascular Approach Himanshu J. Patel, MD, Vikram Sood, BS, David M. Williams, MD, Narasimham L. Dasika, MD, Amy C. Diener, RN, BSN, G. Michael Deeb, MD The Annals of Thoracic Surgery Volume 94, Issue 2, Pages 516-523 (August 2012) DOI: 10.1016/j.athoracsur.2012.03.074 Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Kaplan-Meier survival for the entire cohort. These survival curves demonstrate the dismal prognosis in this patient population: (A) survival of the entire cohort, and (B) survival based on type of therapy. Note that treatment strategy did not affect the primary endpoint of late mortality. (DTAR = descending thoracic aortic repair; TEVAR = thoracic endovascular aortic repair.) The Annals of Thoracic Surgery 2012 94, 516-523DOI: (10.1016/j.athoracsur.2012.03.074) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Kaplan-Meier analysis of treatment efficacy. These curves demonstrate the freedom from aortic rupture or need for reintervention as a result of failure of therapy in the treated or adjacent segment. (A) The entire cohort. (B) Stratification based on treatment showed that endovascular repair was less durable than open repair. (DTAR = descending thoracic aortic repair; TEVAR = thoracic endovascular aortic repair.) The Annals of Thoracic Surgery 2012 94, 516-523DOI: (10.1016/j.athoracsur.2012.03.074) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Effects of intramural hematoma on treatment efficacy. (A) Late failure of the treatment was reduced in the presence of concomitant intramural hematoma (IMH). (B, C) The predominant effect appears to be exerted in the setting of penetrating aortic ulcer (PAU) with IMH treated by endovascular methods. (DTAR = descending thoracic aortic repair; TEVAR = thoracic endovascular aortic repair.) The Annals of Thoracic Surgery 2012 94, 516-523DOI: (10.1016/j.athoracsur.2012.03.074) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Schematic representation of aortic cross section in different pathology. As these diagrams show, the radiographic diagnosis of penetrating aortic ulcers (PAU) can encompass three potential pathologic entities. (A) The first represents a typical branch artery pseudoaneurysm, the natural history of which is benign. (T = thrombus.) (B) The middle schema shows a reentry tear developing in intramural hematoma (IMH), with local excavation of the mural thrombus. As the hematoma resolves, it can be left with an appearance of a penetrating ulcer. The diagnosis of entry tear would have been possible only if the original imaging study, in which the IMH was “fresh,” was available. (C) The final schema represents the original PAU as described by Stanson [1]. (Reprinted from J Vasc Interv Radiol, Vol. 17, Williams DM, Cronin P, Dasika N, Kelly AM, Upchurch GR, Patel HJ, et al. Aortic branch artery pseudoaneurysms accompanying aortic dissection. Part II. Distinction from penetrating atherosclerotic ulcers, Pages 773–81, Copyright 2006 [15], with permission from Elsevier.) The Annals of Thoracic Surgery 2012 94, 516-523DOI: (10.1016/j.athoracsur.2012.03.074) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Example of longitudinal aortic tear. This is an example of an ulcerative lesion running along the long axis of the aorta. In our anecdotal experience, it is not infrequent that progressive “aortic unzipping” occurs at the proximal and distal edges of the tear with resultant rapid growth in aortic diameter. Our institutional preference, based on the perceived virulence of this anatomic presentation, is to consider an operation at a lower threshold. In this photograph, “A” represents the suction device on the medial aspect of the longitudinal tear, and “B” represents a transverse line across the aorta (in contrast to the orthogonally located ulcerative lesion). The Annals of Thoracic Surgery 2012 94, 516-523DOI: (10.1016/j.athoracsur.2012.03.074) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions