Endovascular stent-graft treatment of a ruptured thoracic aortic ulcer

Purpose: To describe a ruptured ulcer of the descending thoracic aorta treated with an endovascular stent-graft deployed under transesophageal echocardiographic (TEE) guidance. Case Report: An 82-year-old man with severe chronic obstructive pulmonary disease and congestive heart failure presented with sharp pain in the back radiating to the left flank. Computed tomography (CT) and angiography demonstrated a penetrating ulcer of the descending thoracic aorta associated with aortic dissection commencing 6 cm from the origin of the left subclavian artery with extravasation of contrast outside the aortic wall. The patient remained symptomatic with a decrease in hematocrit from 36% to 23%. Endovascular repair was performed using self-expanding nitinol stents sutured to a 35-mm X 12-cm Dacron conduit. The device was deployed with a 24-F delivery system under TEE guidance and fluoroscopy. Successful exclusion of the ruptured ulcer was demonstrated by TEE Doppler, arteriography, and CT. The patient remains asymptomatic 18 months after the procedure with no CT evidence of endoleak. Conclusions: Endovascular stent-graft repair under TEE guidance assists in the oftentimes difficult treatment of ruptured penetrating thoracic aortic ulcer.