Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept

Bib Sign in Proximal Descending Thoracic Aorta Rupture on CT Angiography: Presentation of a Paradigmatic Case

Thoracic aortic rupture may present with subtle clinical and CT-angiography findings. Recognition of the imaging features of early rupture is key for timely diagnosis and treatment. This report presents a new sign of incipient proximal thoracic aortic rupture on CT-angiography.

Clinical and Imaging Predictors of Disease Progression in Type B Aortic Intramural Hematomas and Penetrating Aortic Ulcers: A Systematic Review

BACKGROUND

This work aims to review recent literature on penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs), in order to identify clinical and imaging factors connected to aortic-related adverse events (AAE).

METHODS

We performed a systematic review according to the Preferred Reporting Items for Systematic review and Metanalyses (PRISMA) guidelines. An electronic search was conducted on Medline and Embase databases. We included articles reporting on PAUs and/or IMHs localized in the descending thoracic and/or abdominal aorta and analyzing clinical and/or radiological markers of AAE.

RESULTS

Of 964 records identified through database searching, 17 were incorporated in the present review, including 193 and 1298 patients with type B PAUs and IMHs, respectively. The 30-days aortic-related mortality (ARM) was 4.3% and 3.9% for PAUs and IMHs. A total of 21% of patients with IMHs underwent intervention during the follow-up period, and 32% experienced an AAE. PAU markers of AAE were minimum depth (ranging from 9.5 to 15 mm) and diameter (≥12.5 mm). Maximum aortic diameter (MAD) cut-off values ranging from 38 to 44.75 mm were related to AAE for IMHs, together with ulcer-like projection (ULP) of the aortic wall.

CONCLUSIONS

Despite data heterogeneity in the literature, this PAU- and IMH-focused review has highlighted the imaging and clinical markers of disease progression, thus identifying patients that could benefit from an early intervention in order to reduce the AAE rate.

Medically Managed Type A Thoracic Intramural Hematoma and Penetrating Aortic Ulcer

Intramural hematoma (IMH) and a penetrating aortic ulcer (PAU) are included in a larger category of disorders termed acute aortic syndromes. These disorders typically involve the thoracic aorta, abdominal aorta, or both, and often require emergent evaluation and treatment. Both IMH and PAU, much like aortic dissection, are classified using the Stanford and DeBakey systems to indicate the aortic area involved, with Stanford type A (DeBakey type I and II) necessitating surgical intervention, and Stanford type B sufficing with medical management of blood pressure. While IMH and PAU share many characteristics of aortic dissection in terms of diagnosis and initial management, there is much controversy surrounding ultimate treatment. In this report, we describe a case of a Stanford type A IMH with associated PAU that was managed medically with a good outcome.

Predictors of Intervention in Acute Type B Aortic Penetrating Ulcer and Intramural Hematoma

We aimed to investigate predictors of intervention of acute type B aortic penetrating ulcer (PAU) and intramural hematoma (IMH). We conducted a retrospective chart review of all patients admitted for acute type B PAU or IMH in a tertiary referral hospital. Indications to intervention were "complicated" (rupture, impending rupture, malperfusion) or "high risk for unfavorable outcome" (refractory hypertension and/or pain despite best medical treatment, morphologic aortic evolution, transition to a new aortic syndrome, or increase in IMH/PAU depth >5 mm) during the acute/subacute phase. The primary outcomes were overall mortality, aortic-related mortality, and freedom from intervention. Time-dependent outcomes were estimated with Kaplan-Meier curves. Cox proportional hazards models were used to identify predictors of intervention and mortality. There were 54 acute aortic syndromes, 37 PAUs and 17 IMHs. Mean age was 69 ± 14 years and 33 patients (62.2%) were male. Six (11.5%) patients had complicated aortic syndromes and underwent urgent repair. Two (3.7%) additional patients developed an impending rupture during the acute phase. Eleven (21.1%) patients were classified as at "high risk" during the initial hospitalization. Overall, 22 (40.7%) patients required an aortic intervention during the initial admission (n = 16, 72.7% during the acute phase; n = 6, 27.3% during the subacute phase). In-hospital mortality was 5.5% (1 PAU and 2 IMH), and was aorta-related in all cases. For IMH, disease extension in >3 aortic zones (HR 1.94, 95%CI 1.17-32.6; p = 0.038) and presence of ulcer-like projections (ULPs) (HR 1.23, 95%CI 1.02-9.41; p = 0.042) were associated with the need for intervention. There were no aortic-related deaths or intervention during the chronic phase. PAU width >20 mm (HR 1.68, 95%CI 1.07-16.08; p = 0.014), PAU depth >15 mm (HR 6.74, 95%CI 1.31-34.18; p = 021), PAU depth/total aortic diameter >0.3 (HR 4.31, 95%CI 1.17-20.32; p = 0.043), and location at the level of the paravisceral aorta (HR 2.24, 95%CI 1.23-4.70; p = 0.035) were significantly associated with need for intervention. Six additional (16.2%) PAUs required intervention during the chronic phase owing to PAU growth. Maximum aortic diameter >35 mm was significantly associated with intervention (HR 1.45, 95%CI 1.00-2.32; p = 0.037). Acute symptomatic type B IMHs and PAUs are characterized by a high risk of complications during the first month from presentation. Morphologic features associated with intervention were IMH with ULPs or extension in more than 3 aortic zones, as well as PAUs with depth>15 mm, width >20 mm, or depth/aortic diameter ratio>0.3. A strict follow-up protocol or consideration for early intervention within 30 days from presentation should be taken into account for these high-risk patients. During the chronic phase imaging follow-up is particularly important for PAUs in order to identify progression to saccular aneurysms.

Pitfalls and Pearls of Imaging Non-traumatic Thoracic Aortic Disease

Imaging of the thoracic aorta is a common request in both the acute and outpatient settings, playing a crucial role in diagnosis and treatment planning of aortic disease. The findings of aortic pathology may be obvious or occult on imaging. Recognizing subtle changes is essential and may lead to early detection and prevention of serious morbidity and mortality. Knowledge of the anatomy and understanding the pathophysiology of aortic disease, as well as selecting the appropriate imaging modality and protocol will enable prompt diagnosis and early intervention of aortic pathology. Currently, computed tomography angiography and magnetic resonance angiography of the aorta are the most commonly used imaging modalities to evaluate the aorta. This review focuses on a spectrum of aortic pathology manifestations on computed tomography and magnetic resonance, including atherosclerosis and acute aortic syndromes, highlighting diagnostic challenges and approaches to aid in image interpretation.

Diagnosis and Management of Acute Aortic Syndromes: Dissection, Penetrating Aortic Ulcer, and Intramural Hematoma

PURPOSE OF REVIEW

Acute aortic syndromes, including aortic dissection, intramural hematoma, and penetrating aortic ulcer, are a group of highly morbid, related pathologies that are defined by compromised aortic wall integrity. The purpose of this review is to summarize current management strategies for acute aortic syndromes.

RECENT FINDINGS

All acute aortic syndromes have potential for high morbidity and mortality and must be quickly identified and managed with the appropriate algorithm to prevent suboptimal outcomes. Recent trials suggest that TEVAR is increasingly useful in stabilizing pathology of the descending thoracic aorta but when possible should be applied in a delayed fashion and with limited coverage to minimize neurologic complications. Treatment for acute aortic syndrome is frequently dictated by the anatomic location and extent of the wall compromise as well as patient comorbidities. Therapy is often individualized and often includes some combination of medical, procedural, and surgical intervention.

Risk of Aortic Aneurysm and Dissection in Patients with Tuberculosis: A Nationwide Population-Based Cohort Study

Tuberculosis (TB) can cause chronic inflammation. The occurrence of aortic aneurysm (AA) and aortic dissection (AD) may be associated with chronic inflammatory disease, but whether TB increases the risk of AA and AD remains to be determined. This study aimed to investigate the association between TB and the development of AA and AD. We conducted a population-based cohort study using data obtained from the Taiwan National Health Insurance Database. We selected 31,220 individuals with TB and 62,440 individuals without TB by matching the cohorts according to age, sex, and index year at a ratio of 1:2. Cox regression analysis revealed that the TB cohort had a 1.711-fold higher risk of AA and AD than the non-TB cohort after adjustment for sex, age, socioeconomic status, and comorbidities (adjusted hazard ratio = 1.711; 95% confidence interval = 1.098–2.666). Patients with pulmonary, extrapulmonary, and miliary TB had a 1.561-, 1.892-, and 8.334-fold higher risk of AA and AD, respectively. Furthermore, patients with TB at <6 months, 6–12 months, and 1–5 years of follow-up had a 6.896-, 2.671-, and 2.371-fold risk of AA and AD, respectively. Physicians should consider the subsequent development of AA and AD while treating patients with TB.

Sudden Cardiac Arrest Due to Ascending Aortic Thrombus Originating From Penetrating Aortic Ulcer

Penetrating aortic ulcers typically occur in severely diseased vessels. We present the case of a 46-year-old woman, without extensive atherosclerosis, who had sudden cardiac arrest related to ischemia from a mobile intraluminal aortic thrombus adherent to a penetrating ulcer in the ascending aorta. (Level of Difficulty: Intermediate.)

Management of the penetrating atherosclerotic ulcer in the descending thoracic aorta

Penetrating atherosclerotic ulcers present with an insidious onset with a reported mortality of 9%, varying across populations. With vast arrays of risk factors and potentially ominous complications, it is vital to efficiently provide optimum strategies for management. There exists controversy in the literature regarding management, especially for Type B penetrating atherosclerotic ulcers; the decision-making framework encompasses numerous factors in considerations for medical management versus invasive intervention and choice of endovascular versus open repair in the latter. The concomitant presence of intramural haematoma adds further complexity to the already intricate decision-making for management. We performed searches through PubMed and SCOPUS analysing studies reporting outcomes for management strategies for penetrating atherosclerotic ulcers treatment, focusing on Type B, further seeking to analyse studies reporting their experiences of PAU patients with concomitant intramural haematoma. Our review highlights the ambiguity and controversy existing in the literature, comprising studies burdened by their inherent hindering limitations of their single-centre retrospective experiences. Endovascular therapy has come to the forefront of penetrating atherosclerotic ulcers management, often considered first line therapy. In the case of penetrating atherosclerotic ulcers alongside intramural haematoma, there have been reports of potential hybrid surgical approaches to management. Studies further show misdiagnosis of penetrating atherosclerotic ulcers in earlier data sets further complicates management. However, it is clear we must progress on the journey towards precision medicine, allowing delivery of optimum care to our patients.

Ultrasound Imaging of the Abdominal Aorta: A Comprehensive Review

Ultrasound is the imaging modality of choice for the initial evaluation of disorders that involve the abdominal aorta (AA). The diagnostic value of ultrasound resides in its ability to allow assessment of the anatomy and structure of the AA using two- dimensional, three-dimensional, and contrast-enhanced imaging. Moreover, ultrasound permits evaluation of the physiologic and hemodynamic consequences of abnormalities through Doppler interrogation of blood flow, thus enabling the identification and quantification of disorders within the AA and beyond its boundaries. The approach to ultrasound imaging of the AA varies, depending on the purpose of the study and whether it is performed in a radiology or vascular laboratory or in an echocardiography laboratory. The aim of this review is to demonstrate the usefulness of ultrasound imaging for the detection and evaluation of disorders that involve the AA, detail the abnormalities that are detected or further assessed, and outline its value for echocardiographers, sonographers, and radiologists.

Aortic Dissection and Other Acute Aortic Syndromes: Diagnostic Imaging Findings from Acute to Chronic Longitudinal Progression

Acute aortic dissection is the prototype of acute aortic syndromes (AASs), which include intramural hematoma, limited intimal tear, penetrating atherosclerotic ulcer, traumatic or iatrogenic aortic dissection, and leaking or ruptured aortic aneurysm. The manifestation is usually sudden and catastrophic with acutely severe tearing chest or back pain. However, clinical symptoms do not allow distinction between AAS types and other acute pathologic conditions. Diagnostic imaging is essential to rapidly confirm and accurately diagnose the type, magnitude, and complications of AASs. CT fast acquisition of volumetric datasets has become instrumental in diagnosis, surveillance, and intervention planning. Most critical findings affecting initial intervention and prognosis are obtained at CT, including involvement of the ascending aorta, primary intimal tear location, rupture, malperfusion, size and patency of the false lumen, complexity and extent of the dissection, maximum caliber of the aorta, and progression or postintervention complications. Involvement of the ascending aorta-Stanford type A-has the most rapid lethal complications and requires surgical intervention to affect its morbidity and mortality. Lesions not involving the ascending aorta-Stanford type B-have a lesser rate of complications in the acute phase. During the acute to longitudinal progression, various specific and nonspecific imaging findings are encountered, including pleural and pericardial effusions, fluid collections, progression including aortic enlargement, and postoperative changes that can be discerned at CT. A systematic analysis algorithm is proposed for CT of the entire aorta throughout the continuum of AASs into the chronic and posttreated disease state, which synthesizes and communicates salient findings to all care providers. Online supplemental material is available for this article. ^©RSNA, 2021.

Non-A non-B aortic dissection: A literature review

Non-A non-B aortic dissections are an infrequent occurrence and represent a small proportion of aortic dissections. Treating this life-threatening medical emergency often requires surgeons to undertake some one of the most challenging surgical or endovascular cases in medicine. This literature review aims to define and classify non-A non-B dissections, describe their epidemiology as well as their pathology. This review also aims to discuss the range of surgical techniques employed in their treatment and management and to investigate the patient outcomes associated with each technique.

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

This review article describes demographic features, comorbidities, clinical and imaging findings, prognosis, and treatment strategies in penetrating atherosclerotic ulcer (PAU) and closely related entities using google scholar web search. PAU is one of the manifestations of the acute aortic syndrome (AAS) spectrum. The underlying aorta invariably shows atherosclerotic changes or aneurysmal dilatation. Hypertension is the most common contributing factor, with chest or back pain being the usual manifestation. Intramural hematoma (IMH) is the second entity associated with both PAU and aortic dissection (AD), more so with the latter. Chest radiograph can show mediastinal widening, pleural, or pericardial fluid in rupture. Computed tomography angiography (CTA) is the imaging modality of choice to visualize PAU, with magnetic resonance imaging (MRI) and transoesophageal echocardiography (TEE) adding diagnostic value. Lesser-known entities of intramural blood pool (IBP), limited intimal tears (LITs), and focal intimal disruptions (FID) are also encountered. PAU can form fistulous communication with adjacent organs whereas IMH may propagate to dissection. CTA aids in defining the management, open or endovascular options in surgical candidates.

SCMR Position Paper (2020) on clinical indications for cardiovascular magnetic resonance

The Society for Cardiovascular Magnetic Resonance (SCMR) last published its comprehensive expert panel report of clinical indications for CMR in 2004. This new Consensus Panel report brings those indications up to date for 2020 and includes the very substantial increase in scanning techniques, clinical applicability and adoption of CMR worldwide. We have used a nearly identical grading system for indications as in 2004 to ensure comparability with the previous report but have added the presence of randomized controlled trials as evidence for level 1 indications. In addition to the text, tables of the consensus indication levels are included for rapid assimilation and illustrative figures of some key techniques are provided.

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.

A novel risk score on admission for predicting death or need for surgery in patients with acute type A intramural hematoma receiving medical therapy

There has been continuing discussion regarding the treatment strategy for acute type A intramural hematoma (IMH). Most patients are treated conservatively in Japan; hence, predicting fatal events and stratifying risks based on results normally obtained on hospital arrival are important. We aimed to examine the incidences and risk factors of death or need for surgery for acute type A IMH in patients receiving medical treatment and to identify high-risk patients using clinical findings on hospital arrival. From 2011 to 2016, 57 consecutive patients (mean age 72.5 years; male 36.8%) diagnosed with acute type A IMH who were receiving treatment at Shizuoka City Shizuoka Hospital were retrospectively included. Primary endpoint was a composite of cardiovascular death and operation within 1 year after onset. To evaluate sensitivity and specificity of the risk factors and risk score, we estimated the area under the receiver operating characteristic (ROC) curve. Mean follow-up duration was 621 days. Mean systolic blood pressure (SBP) was 129 mmHg. Computed tomography (CT) on arrival showed a mean ascending aorta diameter of 46 mm. Ulcer-like projection (ULP) in the ascending aorta and pericardial effusion (PE) were seen in 33% and 42% of cases, respectively. Twenty-eight patients (49.1%) reached the primary endpoint (cardiovascular death, 7 cases [12.3%]; operation, 21 cases [36.8%]). In univariate analysis of admission values, the primary endpoint group had significantly lower SBP (113.0 ± 28.5 vs 144.3 ± 33.5 mmHg), higher ascending aorta diameter (49.5 ± 8.1 vs 43.6 ± 5.9 mm), and higher frequency of ULP (53.8% vs 13.8%) and PE (58.6% vs 25.0%) than the event-free group. Multivariate analysis showed that ULP on admission CT was a significant predictor of the primary endpoint. The risk score was considered using these risk factors. On admission, the primary endpoint could be predicted with 89.7% sensitivity and 75% specificity (area under the ROC curve 0.823) if the patient had ULP and/or > 2 of the following factors: SBP < 120 mmHg, ascending aorta diameter > 45 mm, and PE. SBP and CT findings on arrival were significantly associated with cardiovascular death and the need for surgery in patients with acute type A IMH receiving initial medical therapy. The novel risk score was useful for predicting cardiovascular death and surgery.

Multidetector Computed Tomography in Traumatic and Nontraumatic Aortic Emergencies: Emphasis on Acute Aortic Syndromes

Aortic emergencies comprise of a list of conditions which are uncommon but are potentially fatal. Prognosis is usually determined by emergent diagnosis and treatment and hence radiology plays a key role in patient management. In this article, we aim to review the various causes of aortic emergencies and the relevant imaging findings placing special emphasis on acute aortic syndromes.

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

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.

Computed Tomography Imaging Findings of Acute Aortic Pathologies

Acute aortic syndromes (AAS) encompass a spectrum of life-threatening conditions characterized by acute aortic pain. AAS include acute aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and aneurysm rupture. The prognosis of AAS is clearly related to prompt diagnosis and appropriate management. The different types of AAS cannot be reliably differentiated solely based on clinical presentation since the clinical features are indistinguishable. Multidetector-row computed tomography (MDCT) with electrocardiographic gating (ECG-gated MDCT) has been used in the acute emergency setting as a powerful clinical tool, which enables rapid and specific diagnosis of aortic pathologies. ECG-gated MDCT significantly reduces motion artifact and avoids potential pitfalls in the diagnosis of AAS. The aim of this review is to evaluate the role of MDCT imaging in the assessment of AAS and to discuss the differentiation of this spectrum of aortic diseases with reference to the key imaging findings.

Mediastinal and Pleural MR Imaging: Practical Approach for Daily Practice

Radiologists in any practice setting should be prepared to use thoracic magnetic resonance (MR) imaging for noncardiac and nonangiographic applications. This begins with understanding the sequence building blocks that can be used to design effective thoracic MR imaging protocols. In most instances, the sequences used in thoracic MR imaging are adapted from protocols used elsewhere in the body. Some modifications, including the addition of electrocardiographic gating or respiratory triggering, may be necessary for certain applications. Once protocols are in place, recognition of clinical scenarios in which thoracic MR imaging can provide value beyond other imaging modalities is essential. MR imaging is particularly beneficial in evaluating for benign features in indeterminate lesions. In lesions that are suspected to be composed of fluid, including mediastinal cysts and lesions composed of dilated lymphatics, MR imaging can confirm the presence of fluid and absence of suspicious enhancement. It can also be used to evaluate for intravoxel lipid, a finding seen in benign residual thymic tissue and thymic hyperplasia. Because of its excellent contrast resolution and potential for subtraction images, MR imaging can interrogate local treatment sites for the development of recurrent tumor on a background of post-treatment changes. In addition to characterization of lesions, thoracic MR imaging can be useful in surgical and treatment planning. By identifying nodular sites of enhancement or areas of diffusion restriction within cystic or necrotic lesions, MR imaging can be used to direct sites for biopsy. MR imaging can help evaluate for local tumor invasion with the application of "real-time" cine sequences to determine whether a lesion is adherent to an adjacent structure or surface. Finally, MR imaging is the modality of choice for imaging potential tumor thrombus. By understanding the role of MR imaging in these clinical scenarios, radiologists can increase the use of thoracic MR imaging for the benefit of improved decision making in the care of patients. ^©RSNA, 2018.

Endovascular Repair of a Penetrating Aortic Ulcer with a Custom-made Relay Stent Graft Featuring a Single Celiac Trunk Fenestration and a Superior Mesenteric Artery Scallop

We report the case of a 70-year-old man with an asymptomatic, fast-growing, paraceliac penetrating aortic ulcer (PAU). Guidelines recommend endovascular repair if an asymptomatic PAU shows a mean growth rate ≥5 mm per year: this patient's maximum aortic diameter was 47 mm but had increased 10 mm in the previous year. The very short sealing zones required a custom-made stent graft. A custom-made relay stent graft comprises a single celiac trunk fenestration, a superior mesenteric artery (SMA) scallop measured according to SMA ostium size, an uncovered distal stent, and 6-mm tapering was used with technical and clinical success.

Spontaneous Rupture of Abdominal Aorta after Seizure in a 23-Year-Old Woman: A Case Report

Spontaneous non-aneurysmal aortic rupture is a rare and life threatening clinical entity. A 23-year-old female patient who visited a nearby hospital due to intractable seizure was transferred to our hospital with the impression of hypotension and decreased level of haemoglobin. She had a history of seizure attacks once a month. However, in the 2 weeks before presentation, the frequency of seizure attacks had increased to 2 to 3 times a day. An abdominal-pelvic computed tomogram scan showed extravasation of contrast from the abdominal aorta at L3 level. An emergency laparotomy revealed a 0.3 cm diameter tear in the posterior wall of the aorta, superior to the iliac bifurcation. We discuss the mechanism of spontaneous aortic rupture and the possibility of aortic rupture related to seizure attacks. (Hong Kong j.emerg.med. 2014;21:103-106)

Emergency Computed Tomography Angiogram of the Chest, Abdomen, and Pelvis

In the setting of blunt trauma, the rapid assessment of internal injuries is essential to prevent potentially fatal outcomes. Computed tomography is a useful diagnostic tool for both screening and diagnosis. In addition to trauma, acute chest syndromes often warrant emergent computed tomographic angiography, looking for etiologies such as aortic aneurysms or complications of aortic aneurysms, or both, pulmonary emboli, as well as other acute vascular process like aortic dissection and Takayasu aortitis. With continued improvements in diagnostic imaging, computed tomographic angiography of the chest, abdominal and pelvis proves to be an effective modality to image the aorta and other major vascular structures.

Penetrating aortic ulcer leading to aortic dissection

Rarely, penetrating atherosclerotic ulcers can rupture into the wall of the aorta, resulting in acute aortic dissection. This article describes a woman with an incidental diagnosis of type A aortic dissection secondary to a penetrating atherosclerotic ulcer of the ascending aorta. Although surgical repair of the aortic root was recommended, the patient refused treatment and left against medical advice.

Multiple Penetrating Atherosclerotic Ulcers of the Aorta: Report of a Case

A 69-year-old hypertensive man who had 7 pseudoaneurysms caused by penetrating atherosclerotic ulcers underwent 2-staged endovascular grafting in the thoracic and thoracoabdominal aorta and a conventional graft replacement of the abdominal aorta. He had an uneventful postoperative course; follow-up computed tomography demonstrated that all aneurysmal lesions treated by endovascular grafting completely disappeared. He has been free from any aortic events 20 months after the last surgery.

A penetrating atherosclerotic ulcer rupture in the ascending aorta with hemopericardium: a case report

Background

Acute aortic syndrome, including classic aortic dissection, intramural aortic hematoma, and penetrating atherosclerotic ulcer (PAU), is a term used to describe a group of conditions with similar clinical symptoms, but with different pathophysiological mechanisms. PAU is a lesion that penetrates the internal elastic lamina through the media. It is usually located in the descending aorta and rarely observed in the ascending aorta.

Case presentation

A 76-year-old man with a history of essential hypertension was brought to the emergency department (ED) because of a sudden-onset chest pain at rest. He had not been taking his medication as ordered. His vital signs in the ED were a blood pressure of 82/60 mmHg, heart rate of 158 beats per min, respiratory rate of 22 breaths per min, and a body temperature of 37.2 °C. An electrocardiogram did not show an ST segment elevation, and cardiac enzymes were within normal limits. No widening mediastinum was found on chest radiography, but a large pericardial effusion with an impending cardiac tamponade was revealed on echocardiography. The diagnosis of PAU rupture in the ascending aorta with hemopericardium was made with chest computed tomography. An emergent sternotomy and ascending aorta reconstruction were performed. A ruptured ulcerative plaque through the intima to the adventitia without flap dissection in the ascending aorta was confirmed. The patient was discharged 18 days after the operation.

Conclusions

Although PAU in the ascending aorta is uncommon, it is commonly lethal when it ruptures. With the current advances in endovascular techniques and devices, endovascular repair of PAU in the ascending aorta is currently recommended only for high-risk patients unsuitable for open repair. However, we anticipate that endovascular repair may become feasible in patients with PAU in the ascending aorta in the future.

Stent-Graft Treatment of Penetrating Thoracic Aortic Ulcers

Purpose:

To evaluate the efficacy of stent-graft placement for the treatment of penetrating thoracic aortic ulcers.

Methods:

Ten patients (7 men; mean age 73.8 years, range 69–79) were treated for penetrating thoracic aortic ulcers using Talent or Excluder stent-grafts. Preoperative examinations included computed tomographic angiography (CTA), transesophageal echography, and digital subtraction angiography (DSA). Follow-up included predischarge multimodal imaging and periodic CTA scans after discharge. Endoleaks, aortic diameter changes, and clinical complications were tracked.

Results:

Technical success was achieved in 100%, but 1 major neurological complication led to death 3 months after the procedure. Radiological follow-up detected 4 early endoleaks (3 type I and a type II), all of which spontaneously regressed, and 1 secondary type II endoleak. The mean aortic diameter decreased by 22% over a mean 9-month follow-up.

Conclusions:

Aortic ulcers are potentially lethal lesions. Considering its low morbidity and mortality, endovascular repair could widen the treatment options for these lesions.

The Acute Abdominal Aorta

Acute disorders of the abdominal aorta are potentially lethal conditions that require prompt evaluation and treatment. Computed tomography (CT) is the primary imaging method for evaluating these conditions because of its availability and speed. Volumetric CT acquisition with multiplanar reconstruction and three-dimensional analysis is now the standard technique for evaluating the aorta. MR imaging may be useful for select applications in stable patients in whom rupture has been excluded. Imaging is indispensable for diagnosis and treatment planning, because management has shifted toward endoluminal repair. Acute abdominal aortic conditions most commonly are complications of aneurysms and atherosclerosis.

[Acute aortic diseases. Diagnostic imaging and therapy]

Diagnostic imaging is crucial in the work-up of acute aortic diseases. Current imaging algorithms enable radiologists differentiating the various entities with subsequent clinically relevant treatment options. Within this educational overview we focus on non-traumatic acute aortic disease. Recent developments of cross sectional imaging are summarized. As for acute aortic disease, we discuss dissections, intramural hematoma, penetrating aortic ulcer, and aortitis. Current treatment options are presented.

Aortic lesion simulating pulmonary disease: a case report

The authors report the case of an elderly woman assessed for dyspnea and right costal margin pain, whose chest radiography demonstrated opacity simulating pulmonary lesion, and computed tomography revealed the vascular origin of the condition. Acute aortic syndrome due to ruptured atheromatous plaque penetrating through the elastic lamina in association with aortic hematoma and aneurysm is a relevant differential diagnosis to be considered in these cases.

MDCT distinguishing features of focal aortic projections (FAP) in acute clinical settings

Focal aortic projections (FAP) are protrusion images of the contrast medium (focal contour irregularity, breaks in the intimal contour, outward lumen bulging or localized blood-filled outpouching) projecting beyond the aortic lumen in the aortic wall and are commonly seen on multidetector computed tomography (MDCT) scans of the chest and abdomen. FAP include several common and uncommon etiologies, which can be demonstrated both in the native aorta, mainly in acute aortic syndromes, and in the post-surgical aorta or after endovascular therapy. They are also found in some types of post-traumatic injuries and in impending rupture of the aneurysms. The expanding, routine use of millimetric or submillimetric collimation of current state-of-the-art MDCT scanners (16 rows and higher) all the time allows the identification and characterization of these small ulcer-like lesions or irregularities in the entire aorta, as either an incidental or expected finding, and provides detailed three-dimensional pictures of these pathologic findings. In this pictorial review, we illustrate the possible significance of FAP and the discriminating MDCT features that help to distinguish among different types of aortic protrusions and their possible evolution. Awareness of some related and distinctive radiologic features in FAP may improve our understanding of aortic diseases, provide further insight into the pathophysiology and natural history, and guide the appropriate management of these lesions.

Comparison of gastric vascular anatomy by monochromatic and polychromatic dual-energy spectral computed tomography imaging

OBJECTIVE

To evaluate the use of monochromatic and polychromatic dual-energy spectral computed tomography (CT) imaging for preoperative assessment of gastric vascular anatomy.

METHODS

Patients with suspected gastric cancer underwent spectral CT to generate conventional 140  kVp polychromatic and monochromatic images with energy levels ranging from 40 to 140  keV during the late arterial and portal venous phases. Optimal monochromatic images were selected according to the contrast-to-noise ratio (CNR) for the gastric artery. Image quality was subjectively assessed. Display rates of the arteries were recorded.

RESULTS

The study included 64 patients. Monochromatic images at 53 ± 3  keV provided the optimum CNR. At this energy level, subjective image scores were significantly higher for monochromatic images than polychromatic images. There were no significant differences in the display rates of arteries between polychromatic and optimal monochromatic images.

CONCLUSIONS

Monochromatic images obtained with spectral CT can improve the visualization of gastric arteries.