Late outcomes with repair of penetrating thoracic aortic ulcers: the merits of an endovascular approach.

Background: Penetrating aortic ulcers (PAU) often occur in a debilitated elderly population. Although early results of repair for PAU are well described, late outcomes remain poorly characterized and are the focus in this report.

Methods: Ninety-five patients (mean age 70.7 years) underwent distal arch/descending aortic repair for PAU (1993 to 2011). Indications for intervention included rupture, saccular aneurysm, or symptoms. Associated intramural hematoma (IMH) was present in 41. Treatment was by open descending aortic repair (DTAR, n=37) or thoracic endovascular aortic repair (TEVAR, n=58). The DTAR group was younger (68 years versus TEVAR 72.5 years, p=0.02), and less frequently presented with rupture (24% versus TEVAR 43%, p=0.09).

Results: Early morbidity included death (9 patients; 9.5%), stroke (8), permanent paraplegia (2), and dialysis (5). Early adverse events were independently predicted by rupture, total descending repair, and DTAR (all p<0.01). Ten-year survival was 47.9%. Predictors of late mortality included advancing age (p=0.016) and urgent presentation (p=0.002), but not repair type. Ten-year freedom from aortic reintervention/rupture was 71.4%. Associated IMH increased the risk for reintervention/rupture (5-year freedom PAU 97.1% versus PAU/IMH 72.1%, p=0.01), primarily because of decreased efficacy after TEVAR for PAU/IMH (5-year freedom 57.7% versus DTAR 100%, p=0.05).

Conclusions: Despite the presence of an older, more complex TEVAR group, late outcomes after repair for PAU were affected more by age and type of presentation than by treatment strategy. Recognizing the perils of intervention in this high-risk population, TEVAR emerges as the therapy of choice to reduce early morbidity and provide similar late survival.