Endovascular Repair of Penetrating Ulcer of the Aortic Arch: A Single-Center Experience

Purpose: Penetrating aortic ulcer (PAU) of the aortic arch is an uncommon entity that presents a challenging management problem because of its close proximity to the supraaortic vessels. The purpose of this study is to report a single-center experience of treating PAU of the arch using a combined procedure of thoracic endovascular aortic repair (TEVAR), supraaortic debranching, and coiling of the PAU.

Materials and Methods: A retrospective review was performed of patients treated for PAU of the aortic arch between 2016 to 2019. Data collected included technical success, 30-day morbidity and mortality rates, and endoleak rate.

Results: During the study period, 8 patients were treated. All patients were men, and the mean age was 70 years. Five of the patients were symptomatic on presentation. The aortic ulcer was located adjacent to the origin of the left subclavian artery in all patients. All patients underwent TEVAR followed by coiling of the aneurysm through a catheter placed within the ulcer before deployment of the stent graft. Four patients underwent supraaortic surgical debranching prior the procedure. Four patients underwent additional endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms during the procedure. Technical success was achieved in all patients. One patient died several hours after surgery from a cardiac event after combined TEVAR and EVAR. Postoperative computed tomography angiography performed in all 6 surviving patients showed exclusion of the PAU with patent supraaortic vessels and bypasses.

Conclusions: A hybrid operation consisting of TEVAR, coiling of the penetrating aortic ulcer, and selective supraaortic debranching is an acceptable treatment option for high-risk patients with a large aortic arch–penetrating ulcer. It can be performed with high technical success rate and minimal morbidity. Further research with large sample size and long-term follow-up is needed.