Management of Aortic Aneurysms with Penetrating Atherosclerotic Ulcers
Critical Risk Assessment and Management
- The American Heart Association recommends urgent surgical consultation for patients with penetrating atherosclerotic ulcers (PAU) in the ascending aorta or arch, due to the high risk of rupture 1
- The American College of Cardiology suggests that PAU requires emergency surgical treatment once diagnosed, as the natural history is more serious than classic aortic dissection 1
Immediate Management Algorithm
- The European Society of Cardiology recommends aggressive blood pressure control with beta-blockers and antihypertensive therapy to reduce aortic wall stress in patients with PAU 1, 2
- The American Heart Association recommends target systolic blood pressure <120 mmHg to minimize shear stress in patients with PAU 1
- Intensive lipid management to LDL-C <55 mg/dL is recommended for patients with atherosclerotic etiology, as suggested by the European Heart Journal 3
Surgical Indications and Approach
- The American College of Cardiology recommends surgical management on an emergency basis for PAU in the ascending aorta or arch, independent of aneurysm size 6, 4
- Aortic arch replacement may be necessary depending on PAU location and extent of arch involvement, as suggested by the American Heart Association 1, 4
- The procedure requires cardiopulmonary bypass with hypothermic circulatory arrest and brain protection strategies, as recommended by the American Heart Association 4
Medical Management Components
- Single antiplatelet therapy (aspirin) is recommended for secondary prevention in patients with PAU, as suggested by the European Heart Journal 3
- Statin therapy with intensive LDL-C lowering target <55 mg/dL is recommended for patients with atherosclerotic etiology, as suggested by the European Heart Journal 3
- Beta-blocker therapy is recommended to reduce aortic wall stress in patients with PAU, as suggested by the American Heart Association 1, 2