Treatment of Acute Type B Penetrating Aortic Ulcer Without Rupture and Without Refractory Symptoms
Clinical Scenario
This protocol addresses the acute type B penetrating aortic ulcer (PAU) that presents without rupture, without refractory pain, and without refractory hypertension — the so-called uncomplicated presentation. Identifying whether high-risk features are present is central to determining the appropriate management pathway.
Key Condition Considerations
Uncomplicated PAU should be managed conservatively during the acute phase, with serial computed tomography imaging to monitor for progression. Endovascular repair is not indicated for all patients in this category — high-risk features must be assessed before considering intervention.
Treatment Approach (Partial Overview)
In selected cases where high-risk features are identified, thoracic endovascular aortic repair (TEVAR) may be considered — typically after the acute phase. Specific technical considerations around graft sizing, sealing zone length, stent design, and management of the left subclavian artery are part of the complete protocol. The full procedural algorithm and selection criteria are detailed in the structured protocol below.
References
DOI: 10.1016/j.ejvs.2025.09.045
- Uncomplicated IMH/PAU should be managed conservatively and followed with serial computed tomography imaging during the acute phase.
- TEVAR is not indicated in patients with uncomplicated acute type B PAU/IMH without high risk features (statement 16, grade A).
- TEVAR may be considered in selected cases with acute uncomplicated PAU/IMH with high risk features (statement 14, grade B).
- In TEVAR planning, a 0 — 10% endograft oversizing should be applied to the proximal (statement 19, grade A) and distal (statement 20, grade B) sealing zones.
- A thoracic endograft without proximal bare stents should be preferred (statement 22, grade B).
- In planning TEVAR for PAU, a proximal sealing length > 20 mm in a site free from PAU associated haematoma should be achieved.
- If the left subclavian artery (LSA) ostium is involved by the disease in patients undergoing urgent or elective TEVAR, LSA patency should be preserved via extra anatomical bypass, branched endograft, or in situ fenestration (statement 17, grade A).
- When performing TEVAR for acute PAU/IMH, intravascular ultrasound may be used intra-operatively to assess landing zones, in situ sizing, or check for eventual graft induced dissection at the proximal or distal landing site.
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