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A 71 year old man presented with severe chest pain followed by collapse. On arrival he was hypotensive, tachycardic, and had a prominent left parasternal thrill. The chest x ray revealed a widened mediastinum. His previous medical history included dialysis dependent chronic renal failure, mild aortic stenosis, hypertension, and asthma.
Transthoracic and transoesophageal echocardiography demonstrated a large pseudoaneurysm of the descending aorta (5.5 cm diameter) with an entry point just distal to the left subclavian artery (panel A). There was extensive mural and protuberant atheroma. Aortography confirmed the diagnosis of a ruptured penetrating aortic ulcer and the extension of the pseudoaneurysm (panel B). As the patient’s operative risk was considered high he underwent emergency endovascular stenting using a 130 mm long, 34 mm diameter, covered stent-graft (Talent, Medtronic, Minneapolis, USA) (panels C and D). The patient made a good recovery and follow up scanning five days later revealed no flow into the aneurysm.
A penetrating atherosclerotic ulcer of the aorta is defined as an ulcerating atherosclerotic lesion that penetrates the elastic lamina. It is associated with haematoma formation within the media of the aortic wall and can lead to aortic dissection, aortic aneurysm, or rupture. The risk of aortic rupture in patients with penetrating ulcers (40%) is significantly higher than in patients with classic type B dissection (3.6%). Urgent intervention is required but emergency surgery is associated with mortality rates of up to 50%. Endovascular stenting now offers an alternative treatment in such high risk patients.
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