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Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146(24):e334-e482. doi:10.1161/CIR.0000000000001106
Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014 Nov 1;35(41):2873-926. doi: 10.1093/eurheartj/ehu281. Epub 2014 Aug 29. Erratum in: Eur Heart J. 2015 Nov 1;36(41):2779. PubMed PMID: 25173340.
Definition, Etiology, PathogenesisTop
Penetrating aortic ulcer (PAU) refers to ulceration of an aortic atherosclerotic plaque that penetrates through the internal elastic lamina into the media. In the acute phase, PAUs may present and are managed in a similar fashion to acute aortic dissections and intramural hematomas.
Clinical Features and Natural HistoryTop
PAU may result in intramural hematoma, pseudoaneurysm, aortic dissection, or aortic rupture. Clinical features usually found in patients with PAU include advanced age, male sex, tobacco smoking, hypertension, coronary artery disease, chronic obstructive pulmonary disease, and abdominal aneurysm. Clinical manifestations may be similar to those in aortic dissection but signs of organ hypoperfusion are rarely seen. PAUs are associated with progressive enlargement of the aorta and development of aneurysms.
DiagnosisTop
Contrast-enhanced computed tomography angiography (CTA) is the study of choice.
TreatmentTop
1. Medical treatment: Control of pain and blood pressure.
2. Invasive treatment: Consider surgery in patients with PAU in the ascending aorta. Indications for invasive treatment in the descending thoracic aorta (preferably endovascular) include symptomatic PAUs (recurrent or refractory pain) as well as signs of contained rupture (a rapidly growing aortic ulcer with periaortic hematoma or pleural effusion).
For asymptomatic PAUs of the descending thoracic aorta and abdominal aorta, there may be those with high-risk imaging features that may be considered for repair. These include a maximum PAU diameter >13 to 20 mm, a maximum PAU depth >10 mm, significant growth in size or depth on serial imaging, PAU associated with a saccular aneurysm, and PAU with an increasing pleural effusion. As PAUs are often seen as incidental findings in elderly patients with significant atherosclerotic disease, decisions regarding intervention must take into account the location/risk of intervention and the comorbidity/life expectancy of the patient.
