Penetrating atherosclerotic ulcer

Penetrating atherosclerotic ulcers (PAU) is a pathology that involves the aortic wall and along with aortic dissection and aortic intramural haematoma form the spectrum known as acute aortic syndrome

Typically, penetrating atherosclerotic ulcers are seen in older male patients with a history of hypertension (up to 92%), smoking (up to 77%) and coronary artery disease (up to 46%) as well as chronic obstructive pulmonary disease (24-68%) 1.

Penetrating atherosclerotic ulcers account for ~7.5% (range 2.3-11%) of all cases of acute aortic syndrome 1. In ~50% (range 42-61%) of cases there are concurrent aortic aneurysms, most often in the abdomen 1.

Typically patients present with symptoms of an acute aortic syndrome, namely acute intense chest pain, often described as tearing, ripping, migrating or pulsating 1,8.

Some of the patients with penetrating atherosclerotic ulcer are asymptomatic and the diagnosis is made incidentally. In the previously cited article they cite the Mayo clinic series 2 in which just 75% of the patients had been symptomatic.

The term "penetrating atherosclerotic ulcer" describes an ulcerating atherosclerotic lesion that penetrates the intima and progresses into the media. In the early stages the lesions just ulcerate the intima and are often asymptomatic. With further progression they ulcerate the media and lead to a hematoma of variable size within the media 3.

The penetrating atherosclerotic ulcer can resolve completely or stay stable, but they can also lead to aortic dissection, aortic saccular aneurysms and even spontaneous aortic rupture. There are conflicting reports about the most common course of the penetrating atherosclerotic ulcer 1.

Location

There is a greater predilection to involve the mid to distal thoracic aorta 6.

CT

On CT angiography of the aorta, the typical finding is a contrast-filled, pouch-like protrusion of the aorta or into the thickened aortic wall in absence of a intimal flap or a false lumen. Often there are signs of extensive atherosclerosis in other sites apart from the ulceration 4.

Usually the ulcer is found in the descending part of the thoracic aorta. Ulcers of the aortic arch are less common, and rare in the ascending aorta 4.

Although associated pleural effusion correlates with clinical instability there are no validated imaging features for prediction of the course of a PAU 1. It is often difficult to determine if a PAU is the source of a patient's pain or if it is an incidental finding.

In follow-up studies increasing maximum diameter and depth of the ulcer is an obvious sign of progression 1.

Transesophageal echocardiogaphy
  • usually TEE demonstrates a localized, crater-like protrusion of the aortic lumen into the thickened aortic wall 9
  • often there are signs of extensive atherosclerosis in other sites apart from the ulceration 9
MRI and MRA
  • T1-weighted SE sequences show a hyperintense hematoma in acute or subacute disease and can distinguish between hematoma and atherosclerotic plaque 9
  • otherwise similar findings to CTA 9
DSA: angiography
  • the typical finding is a contrast-filled, pouch-like protrusion of the aortic lumen 9
  • mostly several oblique projections are required 9
  • ascending aorta
    • although the involvement of the ascending aorta in penetrating atherosclerotic ulcers is rare, the ulcers usually rupture
    • therefore early/urgent or emergent surgical intervention is recommended 4
  • descending aorta
    • may initially be managed with an aggressive (antihypertensive) medical therapy in combination with close clinical and radiographic follow-up
      • if asymptomatic, annual CT imaging follow-up has been suggested 10
    • if there are symptoms or other signs of progression, surgical or endovascular stent-grafting may become necessary 4
Complications

Recognised complications include:

They were first described as a distinct clinical and pathological entity by Stanson et al in 1986 3

General imaging differential considerations include:


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Article Information

rID: 12816
System: Vascular
Section: Pathology
Synonyms or Alternate Spellings:
  • Penetrating atherosclerotic ulcer (PAU)
  • Penetrating aortic ulcer
  • PAU
  • Penetrating aortic ulcers
  • Penetrating atherosclerotic ulceration
  • Penetrating atherosclerotic ulcers

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Cases and Figures

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    Figure 1: diagram of pathogenesis
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    Case 1: involving ascending aorta
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    Penetrating aorti...
    Case 2: involving thoracic aorta : CT
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    Case 2: involving thoracic aorta : angiography
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    Case 3
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    Case 4
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    Case 5
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    Case 6: with aortic intramural haematoma
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