Penetrating atherosclerotic ulcers (PAUs) represent a distinct pathological entity within the spectrum of acute aortic syndromes, characterized by ulceration of atherosclerotic plaque penetrating through the internal elastic lamina into the media of the aortic wall. They typically arise in the setting of advanced atherosclerotic disease, often in patients with a longstanding history of hypertension, hyperlipidemia, and smoking. The process begins with the ulceration of an atherosclerotic plaque, which then erodes into the aortic media. Unlike classic aortic dissection, where an intimal tear leads to the creation of a false lumen, PAUs are localized disruptions that may result in localized hematoma, intramural hematoma (IMH), or progression to saccular aneurysm formation.
Similar to other acute aortic syndromes, PAUs can present with sudden, severe chest/back pain with or without hemodynamics instability. Gated CT angiography is the gold standard for diagnosing PAUs and permits identification of ulcers, intramural hematomas, and aneurysm. Initial medical management begins with impulse control therapies centered around blood pressure and heart rate reduction. Management options range from endovascular techniques such as using a stent-graft to exclude the ulcer and reinforce the aorta wall to open interventions in patients with complex anatomy or infection.
This video demonstrates a coronal CT angiography (showing a descending aortic aneurysm and PAU outpouching) followed by coronal PET scan showing increased tracer activity in the descending aorta concerning for an infected aneurysm.
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