Thoracic Endovascular Repair of Complicated Penetrating Aortic Ulcer: An 11-Year Single-Center Experience.
OBJECTIVE
To analyze an 11-year single-center experience of treating complicated penetrating aortic ulcer (PAU) using thoracic endovascular aortic repair (TEVAR).


METHODS
This study included 63 consecutive patients (mean age 69.1±11.5 years; 40 men) with complicated PAU (42 symptomatic, 22 with rupture) who underwent TEVAR between 2002 and 2013. The PAUs were located in the aortic arch (n=11), the descending thoracic aorta (n=43), and the thoracoabdominal aorta (n=9).


RESULTS
TEVAR was performed within 14 days of diagnosis in 33 (52.3%) cases (19 ruptures treated immediately); the other 30 (47.6%) patients had an average interval between diagnosis and intervention of 40±39 days. Technical success was 98.4% (62/63). One patient had a type I endoleak after stent-graft repair of a PAU in the aortic arch without great vessel transposition; another procedure was required for carotid-subclavian bypass and proximal stent-graft extension. No patient experienced spinal cord ischemia after TEVAR. Five (7.9%) patients died in-hospital; 3 had severe cardiac complications, 1 died from complications of aortic rupture, and the other succumbed to septic shock. Mean follow-up was 45.6±47.2 months, during which 12 (19.0%) patients needed a secondary intervention because of late endoleaks (n=4, 6.3%) or new complications due to disease progression. Multivariate analysis indicated that a PAU depth >15 mm was an independent predictor of mortality (hazard ratio 6.92, p=0.03). In the biomarker analysis, symptomatic patients had significantly higher D-dimer and troponin levels compared to asymptomatic patients [559.5±460.7 vs 283.2±85.2 µg/L (p=0.016) and 0.22±0.61 vs 0.02±0.03 ng/mL (p=0.04), respectively].


CONCLUSIONS
Patients with PAU suffer from underlying severe atherosclerotic disease and have a significant number of cardiovascular comorbidities that lead to relevant mortality and morbidity after TEVAR. As a PAU diameter >15 mm represented high risk for disease progression, these patients may be candidates for early intervention. D-dimer levels may help identify patients at risk and with progression of PAU.
Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany alexander.janosi@uk-essen.de.
Rolf Alexander
RA
Jánosi
Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany.
Riccardo
R
Gorla
Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany.
Konstantinos
K
Tsagakis
Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany.
Philipp
P
Kahlert
Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany.
Michael
M
Horacek
Department of Cardiology, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany.
Florian
F
Bruckschen
Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany.
Daniel-Sebastian
DS
Dohle
Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen and University Duisburg-Essen, Essen, Germany.
Heinz
H
Jakob
Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
Thomas
T
Schlosser
Cardioangiological Center Bethanien (CCB), Frankfurt, Germany.
Holger
H
Eggebrecht
Heart Department, University Hospital, Salerno, Italy.
Eduardo
E
Bossone
Institute of Medical Informatics, Biometry and Epidemiology (IMIBE), University Hospital Essen, University Duisburg-Essen, Essen, Germany.
Raimund
R
Erbel
D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D015415:Biomarkers / Q000097:blood; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D003952:Diagnostic Imaging / Q000379:methods; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D005858:Germany; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014456:Ulcer / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*
D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D
D-dimer; aortic rupture; endograft; endoleak; intramural hematoma; morbidity; mortality; penetrating aortic ulcer; stent-graft; thoracic endovascular aortic repair