Penetran Aortik Ülser ve İntramural Hematomda Cerrahi Tedavi
Özet
Penetran aortik ülser (PAÜ) ve intramural hematom (İMH), akut aortik sendromlar kapsamında yer alır ve ciddi göğüs ağrısına neden olurlar. PAÜ, aterosklerotik plakların aort duvarına zarar vermesi sonucu oluşur ve sıklıkla yaşlı, hipertansif erkeklerde görülür. İntramural hematom ise, vasa vasorumun yırtılması ile media tabakasında kan birikmesi sonucu meydana gelir ve genellikle uzun süreli hipertansiyon ile ilişkilidir. Her iki durumda da tanı genellikle kontrastlı bilgisayarlı tomografi veya manyetik rezonans görüntüleme ile konur. PAÜ ve İMH’nin doğal seyri rüptür, diseksiyon veya anevrizma oluşumu gibi ciddi komplikasyonlarla ilerleyebilir. Tedavi, durumun ciddiyetine ve semptomlara bağlı olarak tıbbi veya cerrahi olabilir. PAÜ’de küçük ve asemptomatik lezyonlar tıbbi olarak yönetilebilirken, semptomatik ve büyük lezyonlar cerrahi müdahale gerektirebilir. İMH’de tip A vakalar genellikle cerrahi ile tedavi edilirken, tip B vakalar öncelikle tıbbi tedavi ile yönetilir. Her iki durumda da, tedavinin amacı kan basıncını kontrol altında tutmak ve hastalığın ilerlemesini önlemektir.
Penetrating aortic ulcer (PAU) and intramural hematoma (IMH) are part of acute aortic syndromes and cause severe chest pain. PAU occurs due to atherosclerotic plaques damaging the aortic wall and is commonly seen in older, hypertensive males. IMH results from blood accumulation in the media layer due to the rupture of the vasa vasorum and is usually associated with long-term hypertension. Diagnosis is typically made through contrast-enhanced computed tomography or magnetic resonance imaging. The natural course of PAU and IMH can lead to serious complications such as rupture, dissection, or aneurysm formation. Treatment depends on the severity and symptoms of the condition and can be either medical or surgical. Small and asymptomatic PAU lesions can be managed medically, while symptomatic and large lesions may require surgical intervention. In IMH, type A cases are generally treated surgically, whereas type B cases are primarily managed with medical therapy. In both conditions, the goal of treatment is to control blood pressure and prevent disease progression.
Referanslar
Yuan X, Clough R, Nienaber C. Acute aortic syndrome. Medicine. 2022;50:449-52.
Shennan T. Dissecting aneurysms. Medical Research Council, special report series no 193. London: His Majesty’s Stationery Office. 1934.
Vilacosta I, Aragoncillo P, Cañadas V, Román JS, Ferreirós J, Rodríguez E. Acute aortic syndrome: a new look at an old conundrum. Postgraduate medical journal. 2010;86(1011):52-61.
Troxler M, Mavor A, Homer‐Vanniasinkam S. Penetrating atherosclerotic ulcers of the aorta. British journal of surgery. 2001;88(9):1169-77.
Gottardi R, Zimpfer D, Funovics M, Schoder M, Lammer J, Wolner E, et al. Mid-term results after endovascular stent-graft placement due to penetrating atherosclerotic ulcers of the thoracic aorta. European journal of cardio-thoracic surgery. 2008;33(6):1019-24.
Quint LE, Williams DM, Francis IR, Monaghan HM, Sonnad SS, Patel S, et al. Ulcerlike lesions of the aorta: imaging features and natural history. Radiology. 2001;218(3):719-23.
Cho KR, Stanson AW, Potter DD, Cherry KJ, Schaff HV, Sundt III TM. Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch. The Journal of Thoracic and Cardiovascular Surgery. 2004;127(5):1393-401.
Brinster DR. Endovascular repair of the descending thoracic aorta for penetrating atherosclerotic ulcer disease. Journal of Cardiac Surgery. 2009;24(2):203-8.
Harris JA, Bis KG, Glover JL, Bendick PJ, Shetty A, Brown OW. Penetrating atherosclerotic ulcers of the aorta. Journal of vascular surgery. 1994;19(1):90-9.
Tittle SL, Lynch RJ, Cole PE, Singh HS, Rizzo JA, Kopf GS, et al. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta. The Journal of Thoracic and Cardiovascular Surgery. 2002;123(6):1051-9.
Ganaha F, Miller DC, Sugimoto K, Do YS, Minamiguchi H, Saito H, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002;106(3):342-8.
Akin I, Kische S, Ince H, Nienaber C. Penetrating aortic ulcer, intramural hematoma, acute aortic syndrome: when to do what. J Cardiovasc Surg (Torino). 2012;53(1 Suppl 1):83-90.
Kazerooni EA, Bree RL, Williams DM. Penetrating atherosclerotic ulcers of the descending thoracic aorta: evaluation with CT and distinction from aortic dissection. Radiology. 1992;183(3):759-65.
Chavan A, Amin S. Management of Acute Aortic Syndrome. 2020. p. 412-21.e1.
DeCarlo C, Latz CA, Boitano LT, Kim Y, Tanious A, Schwartz SI, et al. Prognostication of Asymptomatic Penetrating Aortic Ulcers: A Modern Approach. Circulation. 2021;144(14):1091-101.
members ATF, Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adultThe Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart Journal. 2014;35(41):2873-926.
Oderich GS, Kärkkäinen JM, Reed NR, Tenorio ER, Sandri GA. Penetrating Aortic Ulcer and Intramural Hematoma. CardioVascular and Interventional Radiology. 2019;42(3):321-34.
Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor's Choice – Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery. 2017;53(1):4-52.
Jánosi RA, Gorla R, Tsagakis K, Kahlert P, Horacek M, Bruckschen F, et al. Thoracic Endovascular Repair of Complicated Penetrating Aortic Ulcer:An 11-Year Single-Center Experience. Journal of Endovascular Therapy. 2016;23(1):150-9.
Eggebrecht H, Herold U, Schmermund A, Lind AY, Kuhnt O, Martini S, et al. Endovascular stent-graft treatment of penetrating aortic ulcer: Results over a median follow-up of 27 months. American Heart Journal. 2006;151(2):530-6.
Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, et al. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. European Journal of Cardio-Thoracic Surgery. 2014;47(2):209-17.
Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008;85(1 Suppl):S1-41.
Krukenberg E. Beitrage zur Frage des Aneurysma dissecans. Beitr Pathol Anat. 1920;67:329-51.
Goldberg JB, Kim JB, Sundt TM. Current Understandings and Approach to the Management of Aortic Intramural Hematomas. Seminars in Thoracic and Cardiovascular Surgery. 2014;26(2):123-31.
Uchida K, Imoto K, Karube N, Minami T, Cho T, Goda M, et al. Intramural haematoma should be referred to as thrombosed-type aortic dissection†. European Journal of Cardio-Thoracic Surgery. 2013;44(2):366-9.
Moizumi Y, Komatsu T, Motoyoshi N, Tabayashi K. Clinical features and long-term outcome of type A and type B intramural hematoma of the aorta. The Journal of Thoracic and Cardiovascular Surgery. 2004;127(2):421-7.
Maraj R, Rerkpattanapipat P, Jacobs LE, Makornwattana P, Kotler MN. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol. 2000;86(6):664-8.
Harris KM, Braverman AC, Eagle KA, Woznicki EM, Pyeritz RE, Myrmel T, et al. Acute Aortic Intramural Hematoma. Circulation. 2012;126(11_suppl_1):S91-S6.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Journal of the American College of Cardiology. 2010;55(14):e27-e129.
Evangelista A, Mukherjee D, Mehta RH, O’Gara PT, Fattori R, Cooper JV, et al. Acute intramural hematoma of the aorta: a mystery in evolution. Circulation. 2005;111(8):1063-70.
Hirst Jr AE, Johns Jr VJ, KIME JR SW. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine. 1958;37(3):217.
Sundt TM. Intramural hematoma and penetrating atherosclerotic ulcer of the aorta. The Annals of thoracic surgery. 2007;83(2):S835-S41.
Park K-H, Lim C, Choi JH, Sung K, Kim K, Lee YT, et al. Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma. The Annals of thoracic surgery. 2008;86(5):1494-500.
Svensson LG, Labib SB, Eisenhauer AC, Butterly JR. Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation. 1999;99(10):1331-6.
von Kodolitsch Y, Csösz SK, Koschyk DH, Schalwat I, Loose R, Karck M, et al. Intramural hematoma of the aorta: predictors of progression to dissection and rupture. Circulation. 2003;107(8):1158-63.
Kitai T, Kaji S, Yamamuro A, Tani T, Tamita K, Kinoshita M, et al. Clinical outcomes of medical therapy and timely operation in initially diagnosed type a aortic intramural hematoma: a 20-year experience. Circulation. 2009;120(11_suppl_1):S292-S8.
Song J-K, Kim H-S, Song J-M, Kang D-H, Ha J-W, Rim S-J, et al. Outcomes of medically treated patients with aortic intramural hematoma. The American journal of medicine. 2002;113(3):181-7.
Robbins R, McManus R, Mitchell R, Latter D, Moon M, Olinger G, et al. Management of patients with intramural hematoma of the thoracic aorta. Circulation. 1993;88(5 Pt 2):II1-10.
Song J-K, Yim JH, Ahn J-M, Kim D-H, Kang J-W, Lee TY, et al. Outcomes of patients with acute type a aortic intramural hematoma. Circulation. 2009;120(21):2046-52.
Authors/Task Force m, Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adultThe Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart Journal. 2014;35(41):2873-926.
Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, et al. Insights From the International Registry of Acute Aortic Dissection. Circulation. 2018;137(17):1846-60.
Evangelista A, Eagle KA. Is the optimal management of acute type a aortic intramural hematoma evolving? Circulation. 2009;120(21):2029-32.
Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, et al. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg. 2015;47(2):209-17.
von Kodolitsch Y, Csösz SK, Koschyk DH, Schalwat I, Loose R, Karck M, et al. Intramural hematoma of the aorta: predictors of progression to dissection and rupture. Circulation. 2003;107(8):1158-63.
David L. Brown MD and David Warriner MD P. Acute Aortic Syndromes. Manual of Cardiac Intensive Care2023. p. 205-14.
Referanslar
Yuan X, Clough R, Nienaber C. Acute aortic syndrome. Medicine. 2022;50:449-52.
Shennan T. Dissecting aneurysms. Medical Research Council, special report series no 193. London: His Majesty’s Stationery Office. 1934.
Vilacosta I, Aragoncillo P, Cañadas V, Román JS, Ferreirós J, Rodríguez E. Acute aortic syndrome: a new look at an old conundrum. Postgraduate medical journal. 2010;86(1011):52-61.
Troxler M, Mavor A, Homer‐Vanniasinkam S. Penetrating atherosclerotic ulcers of the aorta. British journal of surgery. 2001;88(9):1169-77.
Gottardi R, Zimpfer D, Funovics M, Schoder M, Lammer J, Wolner E, et al. Mid-term results after endovascular stent-graft placement due to penetrating atherosclerotic ulcers of the thoracic aorta. European journal of cardio-thoracic surgery. 2008;33(6):1019-24.
Quint LE, Williams DM, Francis IR, Monaghan HM, Sonnad SS, Patel S, et al. Ulcerlike lesions of the aorta: imaging features and natural history. Radiology. 2001;218(3):719-23.
Cho KR, Stanson AW, Potter DD, Cherry KJ, Schaff HV, Sundt III TM. Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch. The Journal of Thoracic and Cardiovascular Surgery. 2004;127(5):1393-401.
Brinster DR. Endovascular repair of the descending thoracic aorta for penetrating atherosclerotic ulcer disease. Journal of Cardiac Surgery. 2009;24(2):203-8.
Harris JA, Bis KG, Glover JL, Bendick PJ, Shetty A, Brown OW. Penetrating atherosclerotic ulcers of the aorta. Journal of vascular surgery. 1994;19(1):90-9.
Tittle SL, Lynch RJ, Cole PE, Singh HS, Rizzo JA, Kopf GS, et al. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta. The Journal of Thoracic and Cardiovascular Surgery. 2002;123(6):1051-9.
Ganaha F, Miller DC, Sugimoto K, Do YS, Minamiguchi H, Saito H, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002;106(3):342-8.
Akin I, Kische S, Ince H, Nienaber C. Penetrating aortic ulcer, intramural hematoma, acute aortic syndrome: when to do what. J Cardiovasc Surg (Torino). 2012;53(1 Suppl 1):83-90.
Kazerooni EA, Bree RL, Williams DM. Penetrating atherosclerotic ulcers of the descending thoracic aorta: evaluation with CT and distinction from aortic dissection. Radiology. 1992;183(3):759-65.
Chavan A, Amin S. Management of Acute Aortic Syndrome. 2020. p. 412-21.e1.
DeCarlo C, Latz CA, Boitano LT, Kim Y, Tanious A, Schwartz SI, et al. Prognostication of Asymptomatic Penetrating Aortic Ulcers: A Modern Approach. Circulation. 2021;144(14):1091-101.
members ATF, Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adultThe Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart Journal. 2014;35(41):2873-926.
Oderich GS, Kärkkäinen JM, Reed NR, Tenorio ER, Sandri GA. Penetrating Aortic Ulcer and Intramural Hematoma. CardioVascular and Interventional Radiology. 2019;42(3):321-34.
Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor's Choice – Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery. 2017;53(1):4-52.
Jánosi RA, Gorla R, Tsagakis K, Kahlert P, Horacek M, Bruckschen F, et al. Thoracic Endovascular Repair of Complicated Penetrating Aortic Ulcer:An 11-Year Single-Center Experience. Journal of Endovascular Therapy. 2016;23(1):150-9.
Eggebrecht H, Herold U, Schmermund A, Lind AY, Kuhnt O, Martini S, et al. Endovascular stent-graft treatment of penetrating aortic ulcer: Results over a median follow-up of 27 months. American Heart Journal. 2006;151(2):530-6.
Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, et al. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. European Journal of Cardio-Thoracic Surgery. 2014;47(2):209-17.
Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008;85(1 Suppl):S1-41.
Krukenberg E. Beitrage zur Frage des Aneurysma dissecans. Beitr Pathol Anat. 1920;67:329-51.
Goldberg JB, Kim JB, Sundt TM. Current Understandings and Approach to the Management of Aortic Intramural Hematomas. Seminars in Thoracic and Cardiovascular Surgery. 2014;26(2):123-31.
Uchida K, Imoto K, Karube N, Minami T, Cho T, Goda M, et al. Intramural haematoma should be referred to as thrombosed-type aortic dissection†. European Journal of Cardio-Thoracic Surgery. 2013;44(2):366-9.
Moizumi Y, Komatsu T, Motoyoshi N, Tabayashi K. Clinical features and long-term outcome of type A and type B intramural hematoma of the aorta. The Journal of Thoracic and Cardiovascular Surgery. 2004;127(2):421-7.
Maraj R, Rerkpattanapipat P, Jacobs LE, Makornwattana P, Kotler MN. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol. 2000;86(6):664-8.
Harris KM, Braverman AC, Eagle KA, Woznicki EM, Pyeritz RE, Myrmel T, et al. Acute Aortic Intramural Hematoma. Circulation. 2012;126(11_suppl_1):S91-S6.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Journal of the American College of Cardiology. 2010;55(14):e27-e129.
Evangelista A, Mukherjee D, Mehta RH, O’Gara PT, Fattori R, Cooper JV, et al. Acute intramural hematoma of the aorta: a mystery in evolution. Circulation. 2005;111(8):1063-70.
Hirst Jr AE, Johns Jr VJ, KIME JR SW. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine. 1958;37(3):217.
Sundt TM. Intramural hematoma and penetrating atherosclerotic ulcer of the aorta. The Annals of thoracic surgery. 2007;83(2):S835-S41.
Park K-H, Lim C, Choi JH, Sung K, Kim K, Lee YT, et al. Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma. The Annals of thoracic surgery. 2008;86(5):1494-500.
Svensson LG, Labib SB, Eisenhauer AC, Butterly JR. Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation. 1999;99(10):1331-6.
von Kodolitsch Y, Csösz SK, Koschyk DH, Schalwat I, Loose R, Karck M, et al. Intramural hematoma of the aorta: predictors of progression to dissection and rupture. Circulation. 2003;107(8):1158-63.
Kitai T, Kaji S, Yamamuro A, Tani T, Tamita K, Kinoshita M, et al. Clinical outcomes of medical therapy and timely operation in initially diagnosed type a aortic intramural hematoma: a 20-year experience. Circulation. 2009;120(11_suppl_1):S292-S8.
Song J-K, Kim H-S, Song J-M, Kang D-H, Ha J-W, Rim S-J, et al. Outcomes of medically treated patients with aortic intramural hematoma. The American journal of medicine. 2002;113(3):181-7.
Robbins R, McManus R, Mitchell R, Latter D, Moon M, Olinger G, et al. Management of patients with intramural hematoma of the thoracic aorta. Circulation. 1993;88(5 Pt 2):II1-10.
Song J-K, Yim JH, Ahn J-M, Kim D-H, Kang J-W, Lee TY, et al. Outcomes of patients with acute type a aortic intramural hematoma. Circulation. 2009;120(21):2046-52.
Authors/Task Force m, Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adultThe Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart Journal. 2014;35(41):2873-926.
Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, et al. Insights From the International Registry of Acute Aortic Dissection. Circulation. 2018;137(17):1846-60.
Evangelista A, Eagle KA. Is the optimal management of acute type a aortic intramural hematoma evolving? Circulation. 2009;120(21):2029-32.
Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, et al. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg. 2015;47(2):209-17.
von Kodolitsch Y, Csösz SK, Koschyk DH, Schalwat I, Loose R, Karck M, et al. Intramural hematoma of the aorta: predictors of progression to dissection and rupture. Circulation. 2003;107(8):1158-63.
David L. Brown MD and David Warriner MD P. Acute Aortic Syndromes. Manual of Cardiac Intensive Care2023. p. 205-14.
