Penetrating atherosclerotic ulcer
Updates to Article Attributes
Penetrating atherosclerotic ulcers (PAU) is a pathology that involves the aortic wall. This alongside an and along with aortic dissection and an aortic intramural haematoma, is one of form the possible causes of anspectrum known as acute aortic syndrome.
Epidemiology
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.
Clinical presentation
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.
Pathology
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.
Radiographic features
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
Treatment and prognosis
-
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
- may initially be managed with an aggressive (antihypertensive) medical therapy in combination with close clinical and radiographic follow-up
Complications
Recognised complications include:
- transmural aortic rupture
- embolic phenomena
- pseudo-aneurysm formation
- progressive aneurysmal dilatation
History and etymology
They were first described as a distinct clinical and pathological entity by Stanson et al in 1986 3.
Differential diagnosis
General imaging differential considerations include:
- focal indentation as part of irregularity along mural aortic plaque: could represent a non penetrating atheromatus ulcer.
- aortic intramural haematoma
- aortic dissection
- saccular aneurysm
- (thoracic) aortic injury
-<p><strong>Penetrating atherosclerotic ulcers (PAU)</strong> is a pathology that involves the aortic wall. This alongside an <a href="/articles/aortic-dissection">aortic dissection</a> and an <a href="/articles/aortic-intramural-haematoma">aortic intramural haematoma</a>, is one of the possible causes of an <a href="/articles/acute-aortic-syndrome">acute aortic syndrome</a>. </p><h4>Epidemiology</h4><p>Typically, penetrating atherosclerotic ulcers are seen in older male patients with a history of hypertension (up to 92%), smoking (up to 77%) and <a href="/articles/coronary-artery-disease">coronary artery disease</a> (up to 46%) as well as <a href="/articles/chronic-obstructive-pulmonary-disease-1">chronic obstructive pulmonary disease</a> (24-68%) <sup>1</sup>.</p><p>Penetrating atherosclerotic ulcers account for ~7.5% (range 2.3-11%) of all cases of acute aortic syndrome <sup>1</sup>. In ~50% (range 42-61%) of cases there are concurrent aortic <a href="/articles/aneurysm">aneurysms</a>, most often in the abdomen <sup>1</sup>.</p><h4>Clinical presentation</h4><p>Typically patients present with symptoms of an acute aortic syndrome, namely acute intense chest pain, often described as tearing, ripping, migrating or pulsating <sup>1,8</sup>.</p><p>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 <sup>2</sup> in which just 75% of the patients had been symptomatic.</p><h4>Pathology</h4><p>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 <sup>3</sup>.</p><p>The penetrating atherosclerotic ulcer can resolve completely or stay stable, but they can also lead to <a href="/articles/aortic-dissection">aortic dissection</a>, aortic saccular <a href="/articles/aneurysm">aneurysms</a> and even spontaneous aortic rupture. There are conflicting reports about the most common course of the penetrating atherosclerotic ulcer <sup>1</sup>.</p><h5>Location</h5><p>There is a greater predilection to involve the mid to distal thoracic aorta <sup>6</sup>.</p><h4>Radiographic features</h4><h5>CT</h5><p>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 <sup>4</sup>.</p><p>Usually the ulcer is found in the descending part of the <a href="/articles/thoracic-aorta">thoracic aorta</a>. Ulcers of the <a href="/articles/aortic-arch">aortic arch</a> are less common, and rare in the <a href="/articles/ascending-aorta">ascending aorta</a> <sup>4</sup>.</p><p>Although associated <a href="/articles/pleural-effusion">pleural effusion</a> correlates with clinical instability there are no validated imaging features for prediction of the course of a PAU <sup>1</sup>. It is often difficult to determine if a PAU is the source of a patient's pain or if it is an incidental finding.</p><p>In follow-up studies increasing maximum diameter and depth of the ulcer is an obvious sign of progression <sup>1</sup>.</p><h5>Transesophageal echocardiogaphy</h5><ul>- +<p><strong>Penetrating atherosclerotic ulcers (PAU)</strong> is a pathology that involves the aortic wall and along with <a href="/articles/aortic-dissection">aortic dissection</a> and <a href="/articles/aortic-intramural-haematoma">aortic intramural haematoma</a> form the spectrum known as <a href="/articles/acute-aortic-syndrome">acute aortic syndrome</a>. </p><h4>Epidemiology</h4><p>Typically, penetrating atherosclerotic ulcers are seen in older male patients with a history of hypertension (up to 92%), smoking (up to 77%) and <a href="/articles/coronary-artery-disease">coronary artery disease</a> (up to 46%) as well as <a href="/articles/chronic-obstructive-pulmonary-disease-1">chronic obstructive pulmonary disease</a> (24-68%) <sup>1</sup>.</p><p>Penetrating atherosclerotic ulcers account for ~7.5% (range 2.3-11%) of all cases of acute aortic syndrome <sup>1</sup>. In ~50% (range 42-61%) of cases there are concurrent aortic <a href="/articles/aneurysm">aneurysms</a>, most often in the abdomen <sup>1</sup>.</p><h4>Clinical presentation</h4><p>Typically patients present with symptoms of an acute aortic syndrome, namely acute intense chest pain, often described as tearing, ripping, migrating or pulsating <sup>1,8</sup>.</p><p>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 <sup>2</sup> in which just 75% of the patients had been symptomatic.</p><h4>Pathology</h4><p>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 <sup>3</sup>.</p><p>The penetrating atherosclerotic ulcer can resolve completely or stay stable, but they can also lead to <a href="/articles/aortic-dissection">aortic dissection</a>, aortic saccular <a href="/articles/aneurysm">aneurysms</a> and even spontaneous aortic rupture. There are conflicting reports about the most common course of the penetrating atherosclerotic ulcer <sup>1</sup>.</p><h5>Location</h5><p>There is a greater predilection to involve the mid to distal thoracic aorta <sup>6</sup>.</p><h4>Radiographic features</h4><h5>CT</h5><p>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 <sup>4</sup>.</p><p>Usually the ulcer is found in the descending part of the <a href="/articles/thoracic-aorta">thoracic aorta</a>. Ulcers of the <a href="/articles/aortic-arch">aortic arch</a> are less common, and rare in the <a href="/articles/ascending-aorta">ascending aorta</a> <sup>4</sup>.</p><p>Although associated <a href="/articles/pleural-effusion">pleural effusion</a> correlates with clinical instability there are no validated imaging features for prediction of the course of a PAU <sup>1</sup>. It is often difficult to determine if a PAU is the source of a patient's pain or if it is an incidental finding.</p><p>In follow-up studies increasing maximum diameter and depth of the ulcer is an obvious sign of progression <sup>1</sup>.</p><h5>Transesophageal echocardiogaphy</h5><ul>
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