1. SIR RFS Aortic Angioclub October 24, 2013 Brandon Olivieri, MD Mount Sinai Medical Center of Florida

2. HPI CC: “Burning stomach and back pain” HPI: 70 year-old caucasian male with hx of uncontrolled HTN and 60 pack-yr smoking hx presenting with acute onset 7/10, non-positional burning epigastric pain, radiating to the mid-back. He noted no syncope, no nausea/vomiting.

3. RELEVANT HISTORY PMHx: uncontrolled HTN, 60 pack-yr hx smoking, marijuana – 1 joint daily PSHx: none MEDS: none ALLERGIES: none SOCIAL Hx: Lives alone. No EtOH, no cocaine or IVDA. No formal exercise.

4. PHYSICAL EXAM: BP: 171/77; HR: 94; RR: 20; 98% RA – Gen: elderly male in mild pain, A+Ox3 – Cardiac: RRR. No m/r/g – Pulm: CTAB. No w/r/r – Abd: NT/ND. BS+ – Vascular: peripheral pulses 2+ bilaterally LABS: WBC: 17.7 Hgb: 16.1 Hct: 48.2 Plt: 308 Cr: 0.89 INR: 1.06; PTT: 34.1 LFTs: nl Lipase: 288 T. Chol: 96 Triglycerides: 64 HDL: 32 LDL: 51 Troponin I: <0.040 ECG: NSR, LVH

5. NON-INVASIVE IMAGING 67 HU

6. INCIDENCE: 2.3% - 7.6% acute aortic syndrome PRESENTATION: 40% symptomatic – abdominal or back pain – 29.2% – Hemorrhagic shock -6.9% – Lower limb embolism – 2.6% INDICATIONS for INTERVENTION: – Symptomatic disease – Hypertension – Saccular aneurysm (controversial threshold diameter in differentiating from PAU) NATURAL HISTORY: – Risk of aneurysm rupture related to penetrating ulcers: 13% - 38% – Higher rate of rupture compared to Type A or B dissection – Ulcers with large diameters (5–25 mm and 4–30 mm, respectively) have higher complication rate Natural History of PAUs J Vasc Interv Radiol. 2013 Oct;24(10):1437-1449.e3. doi: 10.1016/j.jvir.2013.05.067. Epub 2013 Aug 7.

7. Penetrating Aortic Ulcer with resultant acute intramural hematoma/Type B dissection – some hematoma propagation into ascending aorta – No clinical practice guidelines for treatment – Treatment Options with complications: Medical management: BP lowering Endograft placement: – Ideal anatomic targets – Procedure-related mortality rates: 1% – In-hospital mortality rates: 5.7% – 12-month clinical failure rate: 8.6% Open Surgical: – Removal of diseased aortic segment with repair with tube or bifurcated graft – Patient likely with increased atherosclerotic burden, poor general health – Procedure-related mortality rates: 4.3% – In-hospital mortality rates: 8.7% – 12-month clinical failure rate: 8.7% Potential Treatments J Vasc Interv Radiol. 2013 Oct;24(10):1437-1449.e3. doi: 10.1016/j.jvir.2013.05.067. Epub 2013 Aug 7.

8. ENDOVASCULAR REPAIR L CFA approach pigtail catheter inserted R CFA cutdown and 22-Fr sheath inserted Lunderquist wire inserted Angiogram demonstrated no evidence of penetrating ulcer or dissection 34 x 34 x 15 cm endoprosthesis placed just distal to the left subclavian artery Post-dilation was not performed

9. CECT: Increase in extent of intramural hematoma distal to the stent graft (green arrow) No evidence of endoleak FOLLOW-UP IMAGING

10. SUMMARY Penetrating Aortic Ulcer with resultant acute intramural hematoma/Type B dissection – some hematoma propagation into ascending aorta Treated endovascularly due to intractable pain Resulted in asymptomatic worsening of penetrating ulcer/Type B dissection distally – Managed medically with aggressive BP control (beta- blockers) and close follow-up

11. REFERENCES Balkoussis NG, Apostolakis EE. Penetrating atherosclerotic ulcer of the thoracic aorta: diagnosis and treatment. Hellenic J Cardiol. 2010 Mar-Apr;51(2):153-7. Batt M, Haudebourg P, Planchard PF, et al. Penetrating atherosclerotic ulcers of the infrarenal aorta: life-threatening lesions. Eur J Vasc Endovasc Surg. 2005;29:35–42 Braverman AC. Penetrating atherosclerotic ulcers of the aorta. Curr Opin Cardiol 1994; 9:591–597. Coady MA, Rizzo JA, Hammond GL, et al. Penetrating ulcer of the thoracic aorta: what is it? How do we recognize it? How do we manage it? J Vasc Surg. 1998 Jun;27(6):1006-15; discussion 1015-6. Vilacosta I, San Roman JA, Aragoncillo P, et al. Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography. J Am Coll Cardiol 1998; 32:83–89.