Penetrating Aortic Ulcers (PAU) are the rarest subset of acute aortic syndromes, and a thoraco-abdominal (TA) location is uncommon (14% of PAU). Endovascular surgery is considered first-line treatment. Custom-made branched/fenestrated endografts have been successfully applied in this disease location, but are unavailable on urgent setting. Off-the-shelf solutions may be required in high-risk patients. The authors describe a case of a symptomatic rapidly expanding TA-PAU without distal seal zone that underwent urgent off-the shelf endovascular repair.
An 81-year-old male presented with acute intense thoracic pain. Workup revealed a large TA-PAU. As pain was refractory and CTA confirmed a rapidly expanding TA-PAU, 13mm above celiac trunk with a 32x30mm pseudoaneurysm with contained rupture (Panel A), urgent repair was proposed. Due to multiple comorbidities and absence of adequate distal seal zone, an off-label endovascular treatment was proposed. The patient underwent successful endovascular repair with two aortic stent-grafts (GORE®cTAG®) with 30% oversize and 50-55mm overlap between aortic modules, combined with chimney self-expanding stent-grafts (GORE® VIABAHN®) to celiac trunk and superior mesenteric artery in a sandwich configuration. Final angiography confirmed PAU exclusion and antegrade rapid visceral flow. Post-operative course was uneventful. Follow-up at 18 months revealed no endoleaks and patent bridging stent-grafts, without visceral compromise (Panel B).
TEVAR is considered the first treatment option for urgent PAU. However, anatomic requirements limit its use in the thoraco-abdominal aorta. Parallel-graft techniques have been described to overcome these anatomical constraints in TA aneurysms. We describe the use of a "sandwich technique" to successfully exclude a PAU without distal sealing zone for standard TEVAR. The advantage was a limited aortic coverage, compared to a branched device or an "octopus" technique. This solution is particularly useful in urgent situations when patients cannot wait for a custom-made device and the morbidity associated with open or hybrid repair is unacceptably high.
TA-PAU are rare. In the urgent setting, endovascular techniques are limited. Off-the-shelf sandwich technique is a potential safe and long-lasting therapeutic option in this clinical scenario"
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