Staged TEVAR strategy for a high-risk type B penetrating aortic ulcer in a patient with concurrent sub-threshold ascending thoracic aortic aneurysm: A case report
Year: 2026
Type: article
Study design: Case Report
Abstract: Background: A penetrating aortic ulcer (PAU) carries a high risk of transmural rupture. An acute, high-risk Type B PAU overlapping with a sub-threshold ascending thoracic aortic aneurysm (ATAA) and secondary aortic regurgitation creates a complex clinical dilemma between localized endovascular repair and highly invasive multi-segment surgical replacement, whereas recommendations for strategic prioritization are sparse in multi-segment aortic disease to prevent premature surgical overtreatment. Case Presentations: A 57-year-old woman presented with sudden, tearing chest pain (VAS 9/10), hypertension emergency (195/110 mmHg), and secondary mild aortic regurgitation. CT angiography (CTA) revealed multi-segment pathology: an acute, high-risk Type B PAU without pseudoaneurysm formation or intramural hematoma in Ishimaru zone 3 at upper curvature (depth: 13.6 mm, neck width: 25.1 mm) coexists with a 4.8-cm fusiform ATAA. Despite meeting guideline-directed anti-impulse targets, due to high-risk features, an urgent thoracic endovascular aortic repair (TEVAR) was performed to isolate the PAU, electing surveillance of the sub-threshold ATAA over high-morbidity total aortic reconstruction. Following complete PAU exclusion (no endoleak) and resolution of pulmonary congestion, the patient was discharged on post-procedure day 2. At 30-day follow-up, she remained asymptomatic with a stable 4.8-cm ATAA on CTA. Conclusions: Morphologic high-risk features of a PAU and a sub-threshold ATAA may justify an early endovascular intervention staged sequencing strategy, despite chronic ascending aortopathy being managed conservatively through surveillance. Keyword : Acute Aortic Syndrome; Aortic Regurgitation; Ascending Thoracic Aortic Aneurysm (ATAA); Thoracic Endovascular Aortic Repair (TEVAR); Type B Penetrating Aortic Ulcer (PAU).
Source: Heart Science Journal
Institutions: University of Brawijaya, RSUD Prof. Dr. Saiful Anwar Malang
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W7221829499