Imperial Vascular Unit, St. Mary's Hospital, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
Bradford Teaching Hospitals, NHS Foundation Trust, Bradford, United Kingdom.
J Vasc Surg. 2020 Jul;72(1):84-91. doi: 10.1016/j.jvs.2019.09.039. Epub 2020 Feb 20.
The optimum management of isolated penetrating aortic ulceration (PAU), with no associated intramural hematoma or aortic dissection is not clear. We evaluate the short- and long-term outcomes in isolated PAU to better inform management strategies.
We conducted a retrospective review of 43 consecutive patients (mean age, 72.2 years; 26 men) with isolated PAU (excluding intramural hematoma/aortic dissection) managed at a single tertiary vascular unit between November 2007 and April 2019. Twenty-one percent had PAU of the arch, 62% of the thoracic aorta, and 17% of the abdominal aorta. Conservative and surgical groups were analyzed separately. Primary outcomes included mortality, PAU progression, and interventional complications.
Initially, 67% of patients (29/43) were managed conservatively; they had significantly smaller PAU neck widths (P = .04), PAU depths (P = .004), and lower rates of associated aneurysmal change (P = .004) compared with those initially requiring surgery. Four patients (4/29) initially managed conservatively eventually required surgical management at a mean time interval of 49.75 months (range, 9.03-104.33 months) primarily owing to aneurysmal degeneration. Initially, 33% of patients (14/43) underwent surgical management; 7 of the 14 procedures were urgent. Of the 18 patients, 17 eventually managed with surgical intervention had an endovascular repair; 2 of the 17 endovascular cases involved supra-aortic debranching, six used scalloped, fenestrated, or chimney stents. The overall long-term mortality was 30% (mean follow-up, 48 months; range, 0-136 months) with no significant difference between the conservatively and surgically managed groups (P = .98). No aortic-related deaths were documented during follow-up in those managed conservatively. There was no in-hospital mortality after surgical repair. Of these 18 patients, two required reintervention within 30 days for type I or III endoleaks. Among the 18 patients, seven died during follow-up (mean survival, 90.24 months; range, 66.48-113.88) with 1 of the 18 having a confirmed aortic-related death.
Isolated, asymptomatic, small PAUs may be safely managed conservatively with regular surveillance. Those with high-risk features or aneurysmal progression require complex strategies for successful treatment with acceptable long-term survival.
孤立性穿透性主动脉溃疡（PAU）无伴发壁内血肿或主动脉夹层时的最佳治疗方法尚不明确。我们评估孤立性 PAU 的短期和长期结局，以更好地为治疗策略提供信息。
我们对 2007 年 11 月至 2019 年 4 月在单一三级血管单位接受治疗的 43 例连续孤立性 PAU（不包括壁内血肿/主动脉夹层）患者（平均年龄 72.2 岁，26 例男性）进行回顾性分析。21%的患者为主动脉弓部 PAU，62%为胸主动脉，17%为腹主动脉。分别对保守治疗组和手术治疗组进行分析。主要结局包括死亡率、PAU 进展和介入并发症。
最初，67%的患者（29/43）接受保守治疗；与最初需要手术的患者相比，他们的 PAU 颈部宽度（P =.04）、PAU 深度（P =.004）更小，且并发动脉瘤变化的发生率更低（P =.004）。最初接受保守治疗的 4 例患者（4/29）最终在平均 49.75 个月（9.03-104.33 个月）的时间间隔内需要手术治疗，主要原因是动脉瘤退行性变。最初，33%的患者（43/14）接受手术治疗；其中 7 例为急症手术。18 例患者中，17 例最终接受了手术干预，其中 17 例采用了血管内修复；其中 2 例血管内病例涉及主动脉弓上分支离断，6 例使用了扇贝形、开窗形或烟囱形支架。总的长期死亡率为 30%（平均随访时间 48 个月，0-136 个月），保守治疗组和手术治疗组之间无显著差异（P =.98）。在保守治疗组中，随访期间没有与主动脉相关的死亡记录。手术修复后无院内死亡。这 18 例患者中有 2 例在 30 天内行再次介入治疗，用于治疗 1 型或 3 型内漏。18 例患者中，7 例在随访期间死亡（平均生存时间 90.24 个月，66.48-113.88 个月），其中 1 例患者死于主动脉相关疾病。
无症状、孤立性、小的 PAU 可安全地接受保守治疗，并定期进行监测。对于有高危特征或动脉瘤进展的患者，需要采用复杂的治疗策略，以获得可接受的长期生存率。
