Penetrating ulcer of the thoracic aorta: natural history, diagnostic, and prognostic profiles

Penetrating aortic ulcers (PAU) result from progressive erosion of atheroma tose plaques perforating the internal elastic lamina. PAU is considered bot h a predisposing condition and differential diagnosis of classic aortic dis section; 93 cases of PAU are documented in the world literature, 60 % of wh ich are male over 60 years old. Systemic hypertension was prevalent in 85 % , history of smoking in 72 %, hyperlipoproteinemia in 35 %, and diabetes me llitus in 31 %. In 61 %, PAU was associated with coronary artery disease, i n 53 % with abdominal or thoracic aortic aneurysm, in 31 % with chronic ren al insufficiency, in 17 % with peripherial artery disease, and in 12 % with a history of cerebrovascular accidents. In 73 %, PAU was associated with f ormation of medial hematoma and in 16 % with a thick, calcified intimal fla p of less than 10 cm extent. Angiography, computed tomography, magnetic res onance imaging and transesophageal echocardiography were used in 66, 63, 23 and 14 %. respectively, for diagnosing PAU; sensitivities for demonstratin g PAU were 83, 65, 86 and 61 %, respectively. Chest or back pain was found in 76 % and an acute onset of symptoms in 68 %. Signs of mediastinal wideni ng were found in 59 %, neurologic signs comprising hoarseness, syncope or c oma in 8 %, pulse differentials caused by embolism in 4 % aortic regurgitat ion in 7 %, and mediastinal hematoma, pleural- or pericardial effusion in 4 2, 27 and 10 %, respectively. PAU of the ascending aorta or aortic arch (ty pe A) leads to dissection and rupture in 57 %, compared to 12 % and 5 %, re spectively, in the descending aorta (type B); 57 % of medically managed typ e A PAU patients died within 30 d of hospital admission compared to only 14 % of type B PAU with 20 cases of uncomplicated long-term outcome without s urgery. Thus, similar to the Stanford classification for aortic dissection, type A PAU should primarily be considered for surgical management, whereas type B PAU without signs of instability may be managed medically.