Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept

Abstract

Penetrating atherosclerotic ulcer is an ulcerating atherosclerotic lesion that penetrates the elastic lamina and is associated with hematoma formation within the media of the aortic wall. This pathologic condition is distinct from classic aortic dissection and aortic rupture; however, care should be taken in making the diagnosis, particularly if the disease is discovered incidentally. At computed tomography (CT), penetrating atherosclerotic ulcer manifests as focal involvement with adjacent subintimal hematoma and is often associated with aortic wall thickening or enhancement. Magnetic resonance imaging is superior to conventional CT in differentiating acute intramural hematoma from atherosclerotic plaque and chronic intraluminal thrombus and allows unenhanced multiplanar imaging. Spiral CT involves shorter examination times and allows high-quality two- and three-dimensional image reconstruction. CT angiography can demonstrate complex spatial relationships, mural abnormalities, and extraluminal pathologic conditions. Transesophageal echocardiography has been reported to be highly sensitive and specific in the differentiation of aortic disease, and intravascular ultrasonography may also be useful in this setting. Although rupture or other life-threatening complications are rare, patients with penetrating atherosclerotic ulcer must be followed up, particularly during the 1st month after onset. Surgical treatment may become necessary in cases involving evidence of intramural hematoma expansion, signs of impending rupture, inability to control pain, or blood pressure changes.

Acute Aortic Syndrome: Recent Trends in Imaging Assessment Using Computed Tomography Angiography

“…The estimated incidence of PAU is 2.3-7.6% in AAS [29]. PAU is usually accompanied by IHM and can lead to aortic dissection, aortic aneurysm, or rupture [40] (Fig. 9).…”

“…Patients with PAU experience persistent or recurrent pain, hemodynamic instability, rapidly expanding aortic diameter, aortic rupture, or distal embolization of the thrombus. The presence of these symptoms is considered an indication for surgical or endovascular repair treatment [40,42]. There is no clear cutoff size for PAU that warrants treatment.…”

Proximal Aortic Dissection with Rupture into the Main Pulmonary Artery—A Case Report

“…The intramural hematoma weakens the aortic wall and may progress either to outward rupture of the aortic wall in 35% of cases or to inward disruption of the intima, leading to communicating dissection in 3% to 5% of cases [38]. In penetrating aortic ulcer, an atheromatous plaque burrowing deeply through the intima into the media [39], the media is exposed to pulsatile arterial flow, which causes hemorrhage into the walls that then leads to intramural hematoma [40] and adventitial erosion may cause rupture in 42% of cases [41]. These nonflap lesions are more common in the descending aorta especially in elderly hypertensive individuals [42].…”

Numerical Simulation in Ulcer-Like Projection due to Type B Aortic Dissection with Complete Thrombosis Type

“…An ulcer-like projection (ULP) that occurs during the course of the complete thrombosis type [10,11] and a penetrating atherosclerotic ulcer (PAU) due to an arteriosclerotic ulcer [12,13] are conceptually different.ULP is an ulcerative projection image of the contrast medium that comparatively has a smooth outline and is a defect of the inner membrane continuous to the false lumen was condensed. Recently, ULP is treated as subtype (ULP type in aortic dissection) [1].…”