Penetrating Aortic Ulcer
Submitted by Anthony Chang, MD

• Ulceration of an atherosclerotic plaque which penetrates into the internal elastic lamina
• Hematoma then forms within the media of the aortic wall
• Occurs in the elderly who usually have a history of severe atherosclerosis, hypertension, and hyperlipidemia
• Similar presentation to those with a descending thoracic aortic dissection i.e. acute chest or back pain
• Plaque ulceration usually in the middle to distal third of the descending aorta
• Intramural hematoma accompanies the penetrating ulcer 80% of the time
• Associated with abdominal aortic aneurysm
• Disease progresses from intimal plaque ulceration to media hematoma formation to adventitial saccular pseudoaneurysm formation and finally rupture if there is transmural penetration
• Speculated as the cause of descending or thrombosed type dissections with all three 

Radiographic findings

• Focal contrast collection projecting beyond the aortic lumen on CT
• Intramural hematoma is indistinguishable from intraluminal thrombus
• Intimal flap is uncommon
• Intramural wall thickening or thrombus is frequently found
• On angiography, there is aortic wall thickening and the ulcerated plaque seen
• On MRI
• High signal intensity on both T1 and T2 with subacute hematoma
• Can be demonstrated by computed tomography, magnetic resonance, angiography and trans-esophageal echocardiography
• Differential diagnosis:
• Aortic dissection (has an intimal flap)
• Atheroma – has a low signal on both T1 and T2  

Treatment

• Surgical cases are those demonstrating hematoma expansion, impending rupture, inability to control blood pressure
• Patients routinely have co-morbid conditions that make them poor surgical candidates and are treated with transluminal placement of endovascular stent grafts

 
Penetrating Aortic Ulcer. Enhanced CT scan through the lower thoracic aorta demonstrates a focal outpouching of contrast posteriorly representing a penetrating aortic ulcer