Endovascular Treatment of a Contained Rupture of a Penetrating Aortic Ulcer in a Young Patient

Penetrating aortic ulcer (PAU) is a component of acute aortic syndromes (AASs), encompassing a range of potentially life-threatening aortic conditions such as dissection, intramural hematoma (IMH), and PAU itself. Ruptured PAU constitutes an emergency requiring surgical intervention. Here, we present a case involving a 47-year-old male patient admitted to our emergency department due to severe abdominal pain, malaise, and tenderness of the abdominal wall, which commenced abruptly several hours prior. An emergency CT scan revealed a large pseudoaneurysm of the infrarenal abdominal aorta, which was found with moderate atherosclerosis and no evidence of other dilated or aneurysmal segments. The patient underwent successful endovascular treatment and was discharged four days later without complications. Follow-up examination after two months demonstrated a patent graft and reduction of the aneurysmal sac.

Beyond the term penetrating aortic ulcer: A morphologic descriptor covering a constellation of entities with different prognoses

Penetrating aortic ulcer (AU) is defined as localized disruption of the intimal layer of the aortic wall, resulting in a crater-like lesion outpouching from the vessel contour. AU is a generic term which encompasses a constellation of entities with different etiologies and prognoses and may be a complication of infective, inflammatory, traumatic, iatrogenic, atherosclerotic processes or intramural hematoma. One of the most challenging scenarios of AU for a differential diagnosis, but also for treatment implications, is when they are associated with acute aortic syndrome. Despite advances in the field of aortic disease, lack of consensus defining these lesions and the significant semantic confusion in the medical literature of the acronym PAU (for penetrating aortic ulcer but also for penetrating atherosclerotic ulcer) have given rise to controversy in guidelines and expert consensus, leading to the same treatment being recommended for entities with different etiology and prognosis. Moreover, in the medical literature, most diagnoses were mainly based on imaging techniques which identified AU regardless of clinical symptoms, surrounding imaging findings or dynamic morphologic changes. In this Review, we provide the latest insight into the differential diagnosis between AU, also called penetrating aortic ulcers, based on clinical context and the newest imaging characteristics to aid treatment decision-making.

The Management of Penetrating Aortic Ulcer

Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management.