Скачать или смотреть Rutherford's 084: Penetrating Aortic Ulcers

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Penetrating Aortic Ulcers (PAUs) are distinct entities within the spectrum of Acute Aortic Syndrome (AAS), which also includes aortic dissection (AD) and intramural hematoma (IMH). Less common than dissections, PAUs represent 2-3% of AAS cases. They develop from atherosclerotic plaque eroding through the inner layer of the aorta, acting like a deep "pothole" in the artery wall. This ulceration can progress, disrupting the middle layer to form an IMH (seen in up to 80% in some reports) or extending through the outer layer, leading to a pseudoaneurysm (~25% of cases). Unlike dissections, PAUs are not typically linked to high hydraulic stress points or genetic conditions like Marfan syndrome; they appear more strongly tied to atherosclerosis.

PAUs most often affect older men, averaging 72 years old, with significant comorbidities like hypertension, smoking, CAD, COPD, and a strong association with abdominal aortic aneurysms (AAAs), present in up to 50% of PAU patients. The descending thoracic aorta is the most common location. Symptoms vary, from severe chest or back pain mimicking dissection to subtle or even entirely absent symptoms (asymptomatic in ~9% of patients). The risk of rupture is location-dependent, potentially higher for symptomatic descending thoracic PAUs and lower in the abdomen.

Diagnosis primarily relies on CTA, the gold standard imaging, which visualizes the ulcer and associated complications like IMH or pseudoaneurysm. MRA and TE are supplementary tools. Treatment depends on symptoms and location. Asymptomatic PAUs outside the ascending aorta are often managed conservatively with strict blood pressure control and surveillance imaging. Symptomatic or complicated PAUs require immediate medical therapy to lower blood pressure/heart rate and prompt intervention. Endovascular repair (T-VAR) is now the primary treatment for most PAUs, especially in the descending aorta. T-VAR offers lower early morbidity and mortality compared to traditional open surgery, making it preferable for the typically older, sicker patient population. However, patients with both PAU and IMH may have a higher risk of requiring reintervention. Lifelong imaging surveillance is crucial after any repair.