SESSION TITLE: Cardiovascular Disease Global Case Reports
SESSION TYPE: Global Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Penetrating aortic ulcer may lead to aortic hematoma, aortic dissection or rupture, as well as distal embolization. This variant of classic aortic dissection is a severe condition that demands accurate diagnosis and treatment. Since the patients are usually elderly and have comorbidities that would increase the complication rates of traditional surgery, endovascular management using endoprosthesis is an important alternative treatment.
CASE PRESENTATION: An 86-year-old female patient, with history of hypertensive cardiovascular disease presented to the emergency department complaining of recurrent substernal chest pain radiating to her back. She was admitted to the Intensive Care Unit (ICU) for blood pressure and pain control. No electrocardiogram or cardiac enzyme abnormalities were noted. A chest computerized tomography (CT) scan demonstrated a Type A aortic wall intramural hematoma (IMH) involving the ascending aorta, from two penetrating ulcers located on its anterolateral and posterior walls. No dissection flap was identified. Those findings were corroborated by both transthoracic echocardiogram exam and aortic angiography. After all treatment options were given to the patient and her family, she was taken to the cardiac catheterization laboratory where an aortic angiography was performed to deploy a 38 x 65mm ascending CMD endoprosthesis device (COOK Medical), just proximal to the brachiocephalic trunk. Angiography was subsequently performed to ensure placement of the endograft. The patient tolerated the procedure, with no major complications in clinical follow-up.
DISCUSSION: Aortic ulcer is a potential source of massive hemorrhage or even chronic chest pain. Shennan first described it in 1934. It occurs most commonly in the descending aorta. Diagnosis is suggested if focal ulcer with adjacent subintimal hematoma is found on CT scan. There is a tendency of Type A IMH to progress to aortic dissection, rupture, or aneurysm formation and an increased mortality. The management of a Type A IMH lacks consensus but, taking into account the profile of patients, endoprosthesis implantation via the femoral artery may be a considerable treatment. Considering her poor clinical condition, that was the choice in our patient.
CONCLUSIONS: Endovascular stent-graft placement is a more conservative and possibly definitive treatment option for Type A IMH when an ascending aortic ulcer can be identified.
Reference #1: Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection. Harris KM1, Braverman AC, Eagle KA, Woznicki EM, Pyeritz RE, Myrmel T, Peterson MD, Voehringer M, Fattori R, Januzzi JL, Gilon D, Montgomery DG,Nienaber CA, Trimarchi S, Isselbacher EM, Evangelista A. Circulation. 2012 Sep 11;126(11 Suppl 1):S91-6.
Reference #2: Endovascular treatment of an acute ascending aortic intramural hematoma. White C, Lapietra A, Santana O, Burke W 3rd, Beasley R, Conde C, Lamelas J. Int J Surg Case Rep. 2014;5(3):126-8. doi: 10.1016/j.ijscr.2013.12.001. Epub 2014 Jan 8.
Reference #3: Percutaneous Management of Penetrating Aortic Ulcer. Carvalho G, Machado MN, Carvalho RB, Neto AC. Arq Bras Cardiol. 2005 Oct;85(4):279-82. Epub 2005 Nov 7.
DISCLOSURE: The following authors have nothing to disclose: Gilberto Franco, Carlos Alves, Pamela Bianchet, Alberto Najjar, Sidney Munhoz, José Alfredo Sejólopes, Samuel Moreira, Paulo Ruiz Lima
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