Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 263-266

Penetrating atherosclerotic aortic ulcer with pseudoaneurysm: Role of hybrid procedure with d-TEVAR

Department of Cardiothoracic and Vascular Surgery, PSG IMSR and Super Specialty Hospital, Coimbatore, Tamil Nadu, India

Date of Submission24-Dec-2021
Date of Decision26-Jan-2022
Date of Acceptance29-Jan-2022
Date of Web Publication21-Aug-2022

Correspondence Address:
Jayasree Rajapandian
Department of Cardiothoracic and Vascular Surgery, PSG IMSR and Super Specialty Hospital, Coimbatore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_134_21

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We present a case of penetrating atherosclerotic aortic ulcer with pseudoaneurysm which was managed by a hybrid partial debranching thoracic endovascular aneurysm repair (d-TEVAR) procedure. A 68-year-old professional singer with multiple comorbidities presented with mid-chest pain radiating to the back for the past 2 months. Computed tomography aortogram revealed a penetrating atherosclerotic ulcer near the summit of the left subclavian artery (LSA) at the distal aortic arch. In view of the high risk of an open-heart surgery, TEVAR procedure with partial debranching of the aortic arch vessel was proposed. As the aneurysm was close to the origin of the LSA, an adequate proximal landing zone was not available. Hence, a bypass from the left common carotid artery to the LSA was done. Following this, an endovascular procedure was performed and the stent graft was placed covering the origin of the LSA. Check aortograms after the procedure revealed patent stent and complete obliteration of the pseudoaneurysm. There was no endoleak noted and the left carotid to subclavian artery bypass was functioning well. The postoperative period was uneventful. Follow-up over a 6-month period was satisfactory. The key elements of a successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough planning, and careful procedural execution. This case demonstrates that a hybrid procedure with partial debranching and thoracic endovascular repair of penetrating aortic ulcers is a safe and less-invasive alternative for elderly, high-risk patients.

Keywords: Acute aortic syndrome, debranching, hybrid procedure, penetrating atherosclerotic ulcer, thoracic endovascular aneurysm repair

How to cite this article:
Periyanarkunan MR, Swamiappan E, Chinnasamy G, Rajapandian J. Penetrating atherosclerotic aortic ulcer with pseudoaneurysm: Role of hybrid procedure with d-TEVAR. Indian J Vasc Endovasc Surg 2022;9:263-6

How to cite this URL:
Periyanarkunan MR, Swamiappan E, Chinnasamy G, Rajapandian J. Penetrating atherosclerotic aortic ulcer with pseudoaneurysm: Role of hybrid procedure with d-TEVAR. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Sep 27];9:263-6. Available from:

  Introduction Top

Open repair of descending thoracic aortic aneurysms is associated with high morbidity and mortality rates. Thoracic endovascular aneurysm repair (TEVAR) for descending thoracic aortic aneurysms was introduced in 1994.[1] It offers long-term outcomes comparable with open surgical repair. With further advances such as a debranching procedure, debranching TEVAR (d-TEVAR) can be relatively safely performed in specific elderly individuals with lower rates of mortality, stroke, spinal cord ischemia, endoleaks, and reinterventions.[2]

  Case Report Top

A 68-year-old professional singer with a past history of systemic hypertension, type 2 diabetes mellitus, and coronary artery disease with previous multiple vessel stenting presented with intense pain over the mid-chest and back for the past 2 months which increased in severity for the past 1 day. On examination, the general condition was fair and vitals were stable. General examination was unremarkable. Computed tomography (CT) aortogram showed a crater in the distal aortic arch [Figure 1] indicating a penetrating atherosclerotic ulcer (PAU) which had progressed into a pseudoaneurysm with a false sac of size 12 mm × 8 mm. Fat stranding adjacent to the aneurysm was noted [Figure 2] suggesting impending rupture. Critical left subclavian artery (LSA) stenosis secondary to the eccentric calcified plaque was seen. The thoracic aorta was heavily calcified, suggestive of extensive atherosclerotic aortic disease. Following thorough consideration of the comorbidities and the high risk that open surgery would pose, a hybrid d-TEVAR procedure was suggested. This is a two-step procedure. The left common carotid artery (LCCA) to LSA bypass followed by TEVAR was performed. As the aneurysm was close to the ostium of the LSA, it had to be covered by stent graft to achieve an adequate landing zone. The subclavian triangle in the left side of the neck was accessed and a bypass was created from the LCCA to the LSA using a 7 mm polytetrafluoroethylene conduit [Figure 3]. This is essentially a partial debranching procedure. Concurrently, TEVAR was performed with bilateral femoral artery access [Figure 4]. A Berenstein catheter was negotiated into the ascending aorta, which was further exchanged for a Stiff Lunderquist wire. Following this, a self-expanding stent graft was deployed across with its proximal end just distal to the LCCA and covering the origin of the LSA. The stent graft used was a multifilament polyester scaffold sewn cylindrically on a nitinol strut of size 31 mm × 31 mm × 174 mm. This makes the proximal landing zone 2 and the distal landing zone 4. Even though the LSA was not clamped due to the extensive calcification present, a check angiogram accessed through the left brachial artery showed no backflow or endoleak [Figure 5]. Postprocedure check angiogram obtained using pigtail catheter revealed that the pseudoaneurysm was completely occluded with patent arch branches. There was no evidence of endoleak [Figure 6]. The patient was observed at the cardiac surgical intensive care unit following the procedure. The postoperative period was uneventful, and he was discharged in 5 days with the relevant medications
Figure 1: Penetrating aortic ulcer near the summit of the left subclavian artery with heavily calcified descending thoracic aorta

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Figure 2: Penetrating aortic ulcer with pseudoaneurysm impending rupture

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Figure 3: Partial debranching procedure

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Figure 4: Before stent deployment, pseudoaneurysm seen

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Figure 5: Flowing left common carotid artery to the left subclavian artery bypass

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Figure 6: Poststent graft, no endo leak

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Outcome and follow-up

At 6 months post-TEVAR with partial debranching procedure, the patient is stable and doing well.

  Discussion Top

Acute aortic syndrome (AAS) comprises three major entities: aortic dissection, intramural hematoma, and PAU.[3] PAU is an ulcerating atherosclerotic lesion that penetrates the external elastic lamina and is associated with hematoma formation within the media of the aortic wall most commonly seen in the descending aorta in elderly hypertensive patients. They usually present with chest pain or back pain that mimics aortic dissection. Furthermore, deep ulceration of atherosclerotic aortic plaques can lead to intramural hematoma formation, pseudoaneurysm, or transmural rupture.[4] Having said that, a PAU with pseudoaneurysm in the distal aortic arch as seen here is relatively uncommon.

Differentiating between PAU and aortic dissection is imperative in these conditions. CT aortogram is used for diagnosis and treatment planning of aortic pathologies. PAUs can present as either a crater-like deformity or an outpouching of the aortic wall with jagged edges with a thickened aortic wall. This is commonly accompanied by extensive calcification of the aorta. These craters are filled with necrotic debris, cholesterol, foam cells which account for the high incidence of embolic phenomenon in these cases.[5]

Asymptomatic PAUs and those present in the descending abdominal aorta are often managed medically using beta-blockers and antihypertensives and regular follow-up imaging. The location of PAU, along with pseudoaneurismal evolution and the presence of symptoms in our patient necessitated an early intervention. Nevertheless, the location of the PAU presented a clinical dilemma, and such cases must be assessed by a multidisciplinary team. Patient selection is key for optimal results.

Open surgery remained the “gold standard” for aortic arch pathologies. However, with recent advances, lesser invasive techniques such as endovascular procedures have taken the limelight, especially in the elderly population who are poor candidates for open surgical repairs. Aortic arch repair is a challenging procedure with significant mortality and stent grafting through TEVAR has found to be effective with reduced perioperative mortality.[6]

Simultaneously, the need for debranching techniques arose. A debranching procedure is one where bypass grafting of the supraaortic branches and ligation of the native branches is implemented. Such debranching procedures reap the benefit of lesser cardiopulmonary bypass and circulatory arrest times.[7] A partial debranching, which has been carried out here, includes bypassing the LCCA and the LSA by approaching the subclavian triangle. Hybrid procedures are instances where both are performed in a two-stage process.

The hybrid arch concept essentially has three main principles: (1) open debranching of the great vessels; (2) creation of proper proximal (zone 0 landing) and distal landing zones; and (3) concomitant or delayed endovascular stent grafting of the aortic arch.[8] A hybrid approach is advantageous as it decreases the magnitude of a single operation into small ones, is minimally invasive with less arch manipulation. Although technically demanding, such hybrid debranching procedures are a valuable alternative to aortic pathologies. We adopted the concept of hybrid aortic arch repair for this case which yielded favorable results.

Learning points

  1. PAU and its complications
  2. Benefits of hybrid d-TEVAR procedure
  3. Aortogram evaluation is a must for both the diagnosis and treatment of AAS.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his/her consent for his/her images and other clinical information to be reported in the journal. The patients understand that his/her name and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Findeiss LK, Cody ME. Endovascular repair of thoracic aortic aneurysms. Semin Intervent Radiol 2011;28:107-17.  Back to cited text no. 1
De Rango P, Cao P, Ferrer C, Simonte G, Coscarella C, Cieri E, et al. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg 2014;59:107-14.  Back to cited text no. 2
Corvera JS. Acute aortic syndrome. Ann Cardiothorac Surg 2016;5:188-93.  Back to cited text no. 3
Hayashi H, Matsuoka Y, Sakamoto I, Sueyoshi E, Okimoto T, Hayashi K, et al. Penetrating atherosclerotic ulcer of the aorta: Imaging features and disease concept. Radiographics 2000;20:995-1005.  Back to cited text no. 4
Nickol J, Richards T, Mullins J. Cholesterol embolization syndrome from penetrating aortic ulcer. Cureus 2020;12:e8670.  Back to cited text no. 5
Chiu P, Goldstone AB, Schaffer JM, Lingala B, Miller DC, Mitchell RS, et al. Endovascular versus open repair of intact descending thoracic aortic aneurysms. J Am Coll Cardiol 2019;73:643-51.  Back to cited text no. 6
Alonso Pérez M, Llaneza Coto JM, Del Castro Madrazo JA, Fernández Prendes C, González Gay M, Zanabili Al-Sibbai A. Debranching aortic surgery. J Thorac Dis 2017;9 Suppl 6:S465-77.  Back to cited text no. 7
Vallabhajosyula P, Szeto WY, Desai N, Komlo C, Bavaria JE. Type II arch hybrid debranching procedure. Ann Cardiothorac Surg 2013;2:378-86.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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