Penetrating atherosclerotic ulcer
Updates to Article Attributes
Penetrating atherosclerotic ulcers (PAU) are a pathology that involves the aortic wall and along with aortic dissection and aortic intramural haematoma form the spectrum 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 in which just 75% of the patients had been symptomatic 2.
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 haematoma 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 aortography, the typical finding is a contrast-filled, out-pouching of the wall of the aorta or into the thickened aortic wall in absence of an intimal flap or a false lumen. The protrusion is said to resemble a mushroom 14. These can progress to an intramural haematoma. 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. However, there is currently no consensus for ulcer depth or diameter that warrants treatment 14.
Transesophageal echocardiography
- usually, transoesophageal echocardiography 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 haematoma in acute or subacute disease and can distinguish between haematoma and atherosclerotic plaque 9
- otherwise similar findings to CTA 9
DSA
- 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
No set guidelines on when to treat and practices vary between hospitals, however the general concensus is as follows:
-
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
-
Asymptomaticasymptomatic:-
Maymay initially be managed with an aggressive (antihypertensive) medical therapy in combination with close clinical and radiographic follow-up-
Annualannual CT imaging follow-up has been suggested 10
-
-
-
Symptomaticsymptomatic or signs of progression:-
Higherhigher risk for spinal cord ischaemia - endovascular stent-grafting (TEVAR)4
-
-
Complications
Recognised complications include:
- transmural aortic rupture
- embolic phenomena
- pseudoaneurysm 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 atheromatous ulcer.
- aortic intramural haematoma
- aortic dissection
- saccular aneurysm
- (thoracic) aortic injury
-<li>Asymptomatic:<ul><li>May initially be managed with an aggressive (antihypertensive) medical therapy in combination with close clinical and radiographic follow-up<ul><li>Annual CT imaging follow-up has been suggested <sup>10</sup>- +<li>asymptomatic:<ul><li>may initially be managed with an aggressive (antihypertensive) medical therapy in combination with close clinical and radiographic follow-up<ul><li>annual CT imaging follow-up has been suggested <sup>10</sup>
-<li>Symptomatic or signs of progression:<ul>-<li>Higher risk for spinal cord ischaemia</li>- +<li>symptomatic or signs of progression:<ul>
- +<li>higher risk for spinal cord ischaemia</li>
Image 11 CT (C+ arterial phase) ( create )
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