Surgical Management of Descending Aorta Penetrating Atherosclerotic Ulcer and Ascending Intramural Hematoma

INTRODUCTION: Management of Penetrating Aortic Ulcer (PAU) and associated Intramural Hematoma (IMH), classically depends on the location of the pathology, but whether medical management or surgical intervention is preferred remains controversial. Management of PAU in the descending thoracic aorta with associated IMH of the ascending aorta remains unclear due to scarcity of reported cases. CASE REPORT: A 68 years old male, hypertensive, was admitted in our unit for sudden-onset of chest pain. CT –Angiography (CTA) demonstrated PAU in the distal portion of aortic arch associated with Type A IMH (thickness 13 mm) without pleuro-pericardial effusion.(Fig.1) The patient was initially treated medically. A CTA control was repeated one week later; it showed IMH thickness decreasing (lower than 10 mm) without change in PAU findings. The patient was discharged at home asymptomatic. Control CTA, scheduled 3 weeks later, showed the presence of a Retrograde Thoracic Acute Aortic Dissection with the entry tear originating from PAU, with flap extension 80 mm in the descending thoracic aorta and an increasing in the diameter of IMH of the ascending aorta (50mm).(Fig.2 ) Patient was scheduled for emergency surgery. Right axillary artery was used as arterial inflow and under Hypothermic Circulatory Arrest and Selective Antegrade Cerebral Perfusion a Frozen Elephant Trunk (30x36 mm) was deployed. A root replacement according to David's tecnique was then performed. Operative data have been: ECC time 375 minutes; SACP 114 minutes; X-clamp 210 minutes. Postoperative course was uneventful and patient was discharged at home in 14° POD. Post-operative CTA showed the aortic remodeling related to aortic root, arch replacement and descending thoracic aorta endografted without evidence of endoleak. Due to the frequency of worsening during follow-up and the favourable surgical results, according to data of the literature, led us to consider for IMH a more aggresive timing of intervention and the use of “FET” permit to treat in a single stage two type of acute aortic syndrome differently located in the Thoracic Aorta

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