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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

Heart Science Journal · Vol. 7 No. 4 (2026) · hlm. 85–89

DOI
10.21776/ub.hsj.2026.007.04.15
ISSN
2721-9984, 2721-9976
Terbit
2026-10-13
Penerbit
Universitas Brawijaya
Bahasa
en
Lisensi
creativecommons.org/licenses/by/4.0

Abstrak

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.

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  • University of Brawijaya
  • RSUD Prof. Dr. Saiful Anwar Malang
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Rekan penulisOrganisasiArtikel bersama
Mohammad Saifur RohmanUniversity of Brawijaya13
Cholid Tri TjahjonoUniversity of Brawijaya12
Sasmojo WiditoUniversity of Brawijaya12
Djanggan SargowoUniversity of Brawijaya10
Ardian RizalUniversity of Brawijaya9
Anna Fuji RahimahUniversity of Brawijaya8
Heny MartiniUniversity of Brawijaya6
Budi SatrijoUniversity of Brawijaya6
Indra PrasetyaUniversity of Brawijaya6
Setyasih AnjarwaniUniversity of Brawijaya4
Seprian WidasmaraUniversity of Brawijaya3
Adhika Prastya WikanandaUniversity of Brawijaya3
Sawitri SatwikajatiUniversity of Brawijaya3
Putri Annisa KamilaUniversity of Brawijaya2
Irma KameliaUniversity of Brawijaya2
Dyah Ayu IkeningrumRSUD Prof. Dr. Saiful Anwar Malang2
Oktafin Srywati PamunaUniversity of Brawijaya2
Zainal FathurohimUniversity of Brawijaya2
Nikhen NoverikeUniversity of Brawijaya2
Titin Andri WihastutiUniversity of Brawijaya2
Ira Vori NugrohoUniversity of Brawijaya2
Imam Mi'raj SuprayogaUniversity of Brawijaya2
Dea Arie KurniawanUniversity of Brawijaya2
Ryan RamadhanUniversity of Brawijaya1
Ardian RizalUniversity of Brawijaya1
Veny KurniawatiUniversity of Brawijaya1
Aris Munandar Zulkifli IsmailUniversity of Brawijaya1
Dedy IrawanUniversity of Brawijaya1
Monika SitioUniversity of Brawijaya1
Muhammad Rizki FadlanUniversity of Brawijaya1
Liemena Harold AdrianRSUD Prof. Dr. Saiful Anwar Malang1
Ayu Asri Devi AdityawatiUniversity of Brawijaya1
Anna Fuji RahimahAfiliasi tidak diketahui1
Imelda KrisnasariUniversity of Brawijaya1
Fahmy RusnantaUniversity of Brawijaya1
Yudi Putra ApridityaUniversity of Brawijaya1
Ratna PancasariUniversity of Brawijaya1
Valerinna Yogibuana Swastika PutriUniversity of Brawijaya1

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Sumber metadata: OAI-PMH (metadata jurnal) https://heartscience.ub.ac.id/index.php/heartscience/oai, pertama di-harvest 8 Nov 2026, terakhir terlihat 8 Nov 2026.
Metadata asli (oai_dc) 
<oai_dc:dc xmlns="http://www.openarchives.org/OAI/2.0/" xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:oai_dc="http://www.openarchives.org/OAI/2.0/oai_dc/" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://www.openarchives.org/OAI/2.0/oai_dc/  http://www.openarchives.org/OAI/2.0/oai_dc.xsd">
	<dc:title xml:lang="en">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</dc:title>
	<dc:creator xml:lang="en">Hutomo, Malombassi Dharmawan Hadiwidjojo</dc:creator>
	<dc:creator xml:lang="en">Kurnianingsih, Novi</dc:creator>
	<dc:subject xml:lang="en">Thoracic Endovascular Aortic Repair (TEVAR)</dc:subject>
	<dc:subject xml:lang="en">Acute Aortic Syndrome</dc:subject>
	<dc:subject xml:lang="en">Type B Penetrating Atherosclerotic Ulcer (PAU)</dc:subject>
	<dc:subject xml:lang="en">Ascending Thoracic Aortic Aneurysm (ATAA)</dc:subject>
	<dc:subject xml:lang="en">Aortic Regurgitation</dc:subject>
	<dc:description xml:lang="en">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.</dc:description>
	<dc:publisher xml:lang="en">Universitas Brawijaya</dc:publisher>
	<dc:date>2026-10-13</dc:date>
	<dc:type>info:eu-repo/semantics/article</dc:type>
	<dc:type>info:eu-repo/semantics/publishedVersion</dc:type>
	<dc:format>application/pdf</dc:format>
	<dc:identifier>https://heartscience.ub.ac.id/index.php/heartscience/article/view/20733</dc:identifier>
	<dc:identifier>10.21776/ub.hsj.2026.007.04.15</dc:identifier>
	<dc:source xml:lang="en">Heart Science Journal; Vol. 7 No. 4 (2026): Navigating High-Risk Cardiovascular Subsets: Premature Disease, Plaque Complexity, and Precision Interventions; 85-89</dc:source>
	<dc:source>2721-9984</dc:source>
	<dc:source>2721-9976</dc:source>
	<dc:source>10.21776/ub.hsj.2026.007.04</dc:source>
	<dc:language>en</dc:language>
	<dc:relation>https://heartscience.ub.ac.id/index.php/heartscience/article/view/20733/626</dc:relation>
	<dc:rights xml:lang="en">Copyright (c) 2026 Malombassi Dharmawan Hadiwidjojo Hutomo, Novi Kurnianingsih</dc:rights>
	<dc:rights xml:lang="en">http://creativecommons.org/licenses/by/4.0</dc:rights>
</oai_dc:dc>