Clinical Significance and Natural History of Incidentally Noted Penetrating Ulcers of the Abdominal Aorta
Brent Safran, MD, Rae Rokosh, MD, Noor Shah, MD, Thomas Maldonado, MD, Neal Cayne, MD, Mikel Sadek, MD, Danny Kim, MD, Glenn Jacobowitz, MD, Caron Rockman, MD.
NYU Langone, NEW YORK, NY, USA.
Penetrating ulcers of the abdominal aorta (PUAA) are a common finding on abdominal imaging studies, however, their significance and natural history are not well documented. The objective of this study was to analyze the patient demographics, presentation, and outcome of subjects who had incidentally discovered PUAA.
A database search of the diagnostic term “penetrating ulcer” was performed of abdominal CT and MRI imaging reports at our institution from January 2014 to December 2017. Patient charts were retrospectively reviewed to determine their baseline medical characteristics, indication for imaging, and subsequent patient course, intervention and outcome. Aortic diameters and PUAA size were measured by a single observer on initial imaging, as well as on follow-up imaging to assess for an association with concomitant aortic pathology and progression of aortic disease.
A total of 92 patients with PUAA were identified; 61 (66.3%) were male. The most common indication for imaging was chest, back, or abdominal pain (21%). The mean age at diagnosis was 79.3 years, and comorbidities included hypertension (73.9%), hyperlipidemia (66%) and malignancy (33.7%). On initial imaging, ulcer size ranged from 0.2 to 3.4 cm, with mean ulcer size measuring 1 cm. Concomitant abdominal aortic dilatation ≥ 3 cm was found in 45% of patients. Mean follow up time was 665 days. Follow-up imaging was performed on 39 (42.4%) of the patients. Of this cohort, the mean PUAA size remained essentially unchanged. However, 46% of patients with subsequent imaging were found to have an increase in overall aortic diameter. Of the total 92 patients, 10 (10.8%) eventually required an open surgical or endovascular intervention, most commonly for aneurysmal disease. No patients required an intervention for an isolated PUAA either initially or in follow-up. All-cause mortality through the end of the follow-up period was 5.5%.
Incidentally discovered PUAA are typically encountered in elderly, comorbid patients receiving imaging for an unrelated indication. At mean follow-up, most PUAA remained unchanged in size. However, a large proportion of the patients were found to have concomitant aortic pathology, particularly aneurysmal disease, which not infrequently required intervention. In conclusion, isolated findings of a PUAA rarely, if ever, require surgical intervention on their own; nevertheless, their association with concomitant aneurysmal disease may warrant routine follow-up imaging.
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