PENETRATING ATHEROSCLEROTIC ULCERS OF THE AORTA

Purpose: This study investigates the natural history and optimal imagi ng modality of penetrating atherosclerotic ulcers of the aorta. Method s: We reviewed our experience with 29 penetrating ulcers in 18 patient s. Computed tomography (17 patients), magnetic resonance imaging (nine patients), and aortography (five patients) were used for diagnosis an d follow-up. Patients were typically elderly (average age 74 years) an d had hypertension and coronary artery disease. Ulcers were most commo n in the distal descending thoracic aorta (31%) and were characterized by a discrete ulcer crater (100%) and thickened aortic wall (89%). Mo des of presentation included chest or back pain in four patients, dist al embolization in two patients, and abnormal chest radiography result s in one; the remaining were incidental findings. Results: Follow-up w as available in ten patients with 17 ulcers from 1 to 7 years. Recurre nt pain occurred in two patients, recurrent embolization occurred in o ne patient, and seven patients remained symptom free. Progression to s accular pseudoaneurysm occurred in five ulcers, and fusiform aneurysm occurred in two ulcers. Two ulcers were associated with an increase in aortic diameter, and nine ulcers did not change. There were no cases of aortic dissection or rupture in the follow-up period. There were no deaths and only one patient underwent resection. Conclusion: The natu ral history of penetrating atherosclerotic ulcers is one of progressiv e aortic enlargement, with saccular and fusiform aneurysms the result if follow-up is sufficient. Aortic dissection, aortic rupture, and emb olization can also occur but are less common. Contrast-enhanced comput ed tomography is the primary imaging modality.