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J Thorac Cardiovasc Surg 2004;127:1393-1401
© 2004 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch

^a Departments of Department of Surgery, Division of Radiology, Mayo Clinic, Rochester, Minn, USA
^b Department of Radiology, Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn, USA
^c Department of Surgery, Division of Vascular Surgery, Mayo Clinic, Rochester, Minn, USA

Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.

Received for publication May 2, 2003; revisions received September 27, 2003; accepted for publication November 4, 2003.

^* Address for reprints: Thoralf M. Sundt III, MD, Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA
Sundt.Thoralf{at}mayo.edu

OBJECTIVE: The clinical behavior of penetrating atherosclerotic ulcers of the aorta is controversial. We reviewed our experience with this entity over a 25-year interval.

METHODS: Cases were identified using the Department of Radiology database searching for the diagnoses of aortic dissection, intramural hematoma, or penetrating ulcer between 1977 and 2002. Available imaging studies were reviewed by a vascular radiologist to confirm the diagnosis of penetrating ulcer and perform serial measurements.

RESULTS: One hundred five patients with penetrating atherosclerotic ulcers of the descending thoracic aorta or arch with (n = 85) or without (n = 20) associated intramural hematoma were confirmed. Two patients with ulcers in the ascending aorta were excluded. There were 73 men and 32 women with a mean age of 72 ± 9 years. Comorbidities included hypertension in 97 (92%), tobacco use in 81 (77%), and coronary artery disease in 48 (46%). Of nonoperated patients with follow-up studies, the mean thickness of the intramural hematoma decreased at 1 month in 89% and completely resolved at 1 year in 85%. There were 3 deaths (4%) within 30 days among 76 patients treated medically and 6 deaths (21%) among 29 patients treated surgically (P < .05). Failure of medical therapy defined as surgery or death was predicted by rupture at presentation (odds ratio = 20.6) and era of treatment (before 1990, odds ratio 9.9) but not aortic diameter, ulcer size, or extent of hematoma.

CONCLUSION: Although careful follow-up is necessary, many penetrating atherosclerotic ulcers of the thoracic aorta can be managed nonoperatively in the acute setting.

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