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

o       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

o       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:

o       Aortic dissection (has an intimal flap)

o       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