International Multicentre Study on the Treatment of Infrarenal Penetrating Aortic Ulcers

Objective: This study aimed to evaluate treatment indications, compare therapeutic approaches, and assess outcomes in patients with infrarenal penetrating aortic ulcers (iPAUs). Methods: This was a retrospective, multicentre, observational study of patients with iPAUs treated between January 2018 and December 2022 across 12 European centres. Treatment strategies included open surgical repair (OSR) and endovascular techniques, including balloon expandable stent grafts (BESGs), covered endovascular reconstruction of the aortic bifurcation (CERAB), and endovascular aortic repair (EVAR) using bifurcated or tube grafts. Primary endpoints were technical success, anatomy dependent graft selection, and safety outcomes. Results: Among 260 patients (mean age 74.2 years, 77.7% male), 96.9% (n = 252) underwent endovascular repair. PAU size was the primary indication in 70.4% of cases. Bifurcated grafts were used in 64.7% (n = 163) and tube grafts in 35.3% (n = 89). Bifurcated grafts were more frequently selected for patients with larger proximal landing zones (21 ± 3 mm vs. 18 ± 5 mm; p < .001), wider aortic bifurcation diameters (20 ± 5 mm vs. 18 ± 4 mm; p < .001), shorter PAU to bifurcation distances (30 ± 24 mm vs. 41 ± 33 mm; p = .003), and larger PAU base diameters (median 22 mm [interquartile range 16, 30] vs. 18 mm [interquartile range 12, 25]; p < .001). Although few patients underwent OSR, the group had high technical success and no 30 day mortality. Technical success rates were 97.8% for BESGs, 100% for CERAB, and 99.3% for EVAR. Median hospital stay was 4 days. Major adverse events occurred in 3.5%, with a 30 day mortality rate of 1.5% and a re-intervention rate of 8.1%. Chronic obstructive pulmonary disease independently predicted 30 day mortality (odds ratio [OR] 4.063; p = .039) and major adverse events (OR 7.181; p = .035). Over a median follow up of 21.2 months, overall mortality was 19.3% (9.4% aortic related), with a re-intervention rate of 9.9% (9.4% aortic related). Conclusion: Endovascular repair, especially with bifurcated grafts, was the preferred safe approach. CERAB and BESGs were effective in anatomically suitable cases.