Penetrating Ulcer of Aortic Arch

How would you manage this 76 year old chap?

The diagnosis is probably a penetrating aortic ulcer, with mural thrombus, in an artherosclerotic calcified aorta. No specific guidelines exist, but it looks a reasonable size and so must posse a risk of spontaneous rupture. Surgery would be very high risk, and isolated stenting would be difficult, as the stent would cover the head and neck vessels. 

It should be noted that in this chap he has 4 vessels emanating from the arch, due to an aberrant left vertebral artery. 

A hybrid procedure with extra anatomical grafting of the head and neck vessels and stenting the aneurysm, is probably the procedure of choice in this elderly chap.

With regard to extra anatomical bypass, a number of options exist, (none of which are probably correct)

• Bypass innominate and left carotid artery as usual and tie of vertebral. ( may be an option if you have demonstrated completeness of the circle of Willis, or if the radiologists have inflated a balloon in the vessel when the patient is awake a to occlude any flow and the patient has had no neurological symptoms)

• Bypass innominate and left carotid artery as usual and re implant vertebral artery as a button.

All this can be done off pump, but with bypass and hypothermia, even at 32^oC, the chances of any cerebral damage should probably be reduced. It is important to tie off vessels after extra anatomical bypass to reduce the chances of an endoleak.

The role of barbiturates, steroids, propofol, and packing the head in ice remain controversial.