Penetrating Atherosclerotic Ulcers of the Abdominal Aorta: A Case Report and Review of the Literature

Abstract

Penetrating atherosclerotic ulcers (PAUs) of the aorta are defined as atherosclerotic lesions with aortic intima and media ulceration, which may lead to a complete rupture of the adventitial wall. The present article aimed to report an unusual case of a surgically treated patient with abdominal aorta PAU with an illustration of the key features and to review and analyze the existing literature data. PAUs typically develop in elderly and hypertensive patients and in patients with advanced atherosclerosis. Although originally described for the descending thoracic aorta, a similar clinicopathological entity also occurs in the abdominal aorta. Patients with symptoms of a PAU should be treated immediately if they are fit for surgery. Exceptive observation by imaging modalities is necessary in patients with asymptomatic small (<2 cm) PAU, with or without focal dissection.

Demystifying penetrating atherosclerotic ulcer of aorta: unrealised tyrant of senile aortic changes

“…1,39 An interesting differential of PAU involving abdominal aorta is inflammatory aneurysm characterized by marked wall thickening and associated fibrosis forming surrounding adhesions. 56 The conventional angiographic and CTA appearance of PAU is similar to a gastric or duodenal ulcer seen in barium studies. 6,13,17 PAU usually does not extend beyond the aortic contour, latter being suspicious for rupture, associated hematoma or Subintimal pseudoaneurysm formation.…”

“…1,39 PAU is seen on CTA as contrast filled outpouching (Figures 1, 2) or crater-like morphology on aortography and TEE. 4,6,56 PAU ranges in size from few millimeters to 2.5 cm, depth up to 3 cm, are often multiple. 36 There is invariable surrounding IMH and medially displaced calcified intima (Figure 3).…”

“…Hemodynamic instability, persistent or increasing pain despite treatment, larger aortic diameter >55-60 mm or aneurysm formation, a continual increase in diameter, contained or frank rupture, hemopericardium, or large hemothorax are established criteria to undertake surgical approach irrespective of the involved aortic segment. 4,6,7,10,39,[56][57][58][59][60][64][65][73][74][75] In cases of PAU localized to ascending aorta and/or arch urgent surgical management whether open surgical or thoracic endovascular aortic repair (TEVAR) is warranted. There is no uniform consensus as to when to choose between expectant and surgical management in cases of PAU localized to descending aorta.…”

“…16,71 The presence of IMH seems to delay the effectiveness of the treatment, although the risk of endoleak or stent migration is negligible. 56 Stent grafts provide an advantage in terms of obviating embolic events by preventing the migration of debris or fragments. TEVAR also has a particular advantage in cases of paravisceral PAU, with the placement of branching grafts.…”

“…71 The open surgical procedure is also preferred in the younger age group, which has a relatively lower risk making the former comparable with TEVAR. 56 The follow-up of symptomatic patients should be done at 1,3,6 and 12 months followed by every year if the disease remains stable. For asymptomatic cases, the follow-up can be done six monthly for the first three years, followed by annual surveillance.…”