Acute Aortic Disease.. - Index of

288 Brinster et al.
conventional open surgical repair, TEVAR in centers with expertise provides a
surgical alternative for patients typically associated with poor outcome.
Penetrating Atherosclerotic Ulcer/Intramural Hematoma
Historically, penetrating atherosclerotic ulcer (PAU) with intramural hematoma
(IMH) in the descending thoracic aorta have been managed medically. The behavior
and optimal clinical management of PAU and IMH in the descending thoracic aorta
are not well defined and remain a clinical challenge. Furthermore, the natural history
of PAU and IMH remains unclear (62–64). Cho et al. (65) recently reviewed
the Mayo Clinic experience with PAU of the descending thoracic aorta over a
25-year period. From 1977 to 2002, 105 patients with PAU of the descending
thoracic aorta with (n = 85) and without (n = 20) IMH were included in the study.
The medical group included 76 patients and the surgical group included 29 patients.
Thirty-day mortality in the medical group was 4% versus 21% in the surgery
group (P < 0.5). Defined as conversion to surgery or death, failure of medical therapy
was predicted by presence of rupture at presentation and the era of treatment
(before 1990). Aortic diameter, ulcer, or extent of hematoma were not risk factors
for medical therapy failure or death.
The introduction of TEVAR has prompted investigators to examined the
role of this new technology in descending thoracic aortic PAU and IMH. Jin et al.
(66) reported their experience with TEVAR for PAU in the descending thoracic
aorta. In their series of 14 patients, the majority of patients were symptomatic and
were treated emergently. Endoleaks were present in two patients at completion
angiography. With a mean follow-up period of 17.2 months, coverage of PAU was
achieved in all patients with complete reabsorption of IMH in two patients. One
patient died of rupture of psuedoaneurysm at one month after surgery. Other
investigators have also reported small series of endovascular aortic stent graft
therapy for PAU and IMH (67,68,133). Technical success with good short-term
followup has been demonstrated with no mortality.
In summary, TEVAR for PAU and IMH in the descending thoracic aorta is
promising. Endovascular therapy for complicated or symptomatic PAU appears to
be indicated. However, more evidence and long-term follow-up is needed for
definitive conclusion.
Traumatic Transection
Traumatic aortic injury resulting from blunt trauma is often associated with high
morbidity and mortality, with the majority of patients dying at the scene (69).
Rarely is traumatic transection an isolated injury, as the majority of patients sustain
other concomitant orthopedic, neurosurgical, and abdomen injuries. Mortality
rates in most recent surgical series range from 11% to 40% (69–71). Paraplegia
rate ranges from 0% to 20% (70,72,73), depending on the operative technique and
circulatory management employed. Often, concomitant nonaortic injuries may
preclude immediate surgical repair of the aorta. This may be due to issues regarding