Penetrating Atherosclerotic UlcerPenetrating Atherosclerotic Ulcer of the Aortaof the Aorta Imaging Features and Disease Concept

Present by : Ekksit Srithammasit, MDPresent by : Ekksit Srithammasit, MD

RadioGraphics 2000; 20:995–1005

Hayashi et al,Department of Radiology, Nagasaki University School of Medicine,

IntroductionIntroduction

Penetrating Atherosclerotic Ulcer an ulcerating atherosclerotic

lesion that penetrates the elastic lamina and is associated with hematoma formation within the media of the aortic wall

- First described by Stanson et al in 1986 -

Table of ContentsTable of Contents

Disease Course Imaging Appearances Prognosis Management Relationship between

Penetrating Atherosclerotic Ulcer and Aortic Dissection

Disease CourseDisease Course

Imaging AppearancesImaging Appearances

Angiogram : CT : MRI Generally use spiral CT to evaluate aortic

disease. the shorter examination times. high-quality 2D & 3D image reconstructions. demonstrate mural abnormalities, and

extraluminal pathologic conditions.

Imaging AppearancesImaging Appearances

CT features of penetrating ulcers Focal involvement with adjacent subintimal hematoma

located beneath the frequently calcified and inwardly displaced intima in the middle or distal third of the thoracic aorta.

The ulcer is often associated with thickening or enhancement of the aortic wall.

Vilacosta et al described as A craterlike or focal outpouching in the atherosclerotic

wall that occurs in the middle to distal portion of the descending thoracic aorta.

Contrast-enhanced CT scan

A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain.A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain.

CECT : after conservative treatment at 14 and 35 days Surgical treatment was not attempted, and the patient died 36 days

after onset with severe hematemesis due to an aortoesophageal fistula.

A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain.A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain.

Photograph of the autopsy specimen

A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain.A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain.

Low-power photomicrograph

A 74- year-old man with sudden onset of chest pain.A 74- year-old man with sudden onset of chest pain.

CECT Thoracic aortogram

A 74- year-old man with sudden onset of chest pain.A 74- year-old man with sudden onset of chest pain.

Follow-up CT scans obtained 7 (b) and 21 (c) days after onset The patient underwent surgery, the results of which confirmed

penetrating atherosclerotic ulcer.

A 73-year-old man with back pain.A 73-year-old man with back pain.

Over 5 years later, the patient remains asymptomatic and the penetrating atherosclerotic ulcer remains unchanged in size

CECT

48 hours later

CECT

48 hours later

Oblique sagittal cine MRI

3 months later

Imaging AppearancesImaging Appearances

Typically involve the descending thoracic aorta but can also involve the abdominal aorta, which is sometimes more severely atherosclerotic.

Multiple penetrating atherosclerotic ulcers may also be seen.

A 73-year-old man with back pain.A 73-year-old man with back pain.

The patient was treated conservatively.

CECT CECT

2 weeks

CECT

2 years

A 73-year-old man with back pain.A 73-year-old man with back pain.

The patient was treated conservatively.

A 73-year-old man with back pain.A 73-year-old man with back pain.

Unenhanced CT scan CECT

A 73-year-old man with back pain.A 73-year-old man with back pain.

Follow-up contrast-enhanced CT scan obtained 2 weeks after onset

PrognosisPrognosis

Little is known about the natural history of penetrating atherosclerotic ulcer. This disease entity has been considered by

most authors to have a poorer prognosis than classic aortic dissection.

However, Harris et al reported that disease progression is slow, with a low prevalence of acute rupture or other life-threatening complications.

Although cases of penetrating atherosclerotic ulcer typically have many features in common the prognosis was different from case to case.

PrognosisPrognosis In our experience

the prevalence of critical cases of symptomatic penetrating atherosclerotic ulcer is higher than that of classic aortic dissection.

Coady et al reported the risk of aortic rupture was considerably

higher among patients with penetrating atherosclerotic ulcer than among patients with aortic dissection.

PrognosisPrognosis We occasionally encountered a saccular

aneurysm, which seemed to be caused by a penetrating atherosclerotic ulcer.

Although rupture or other life-threatening complications are rare, affected patients must be followed up because such complications can progress slowly.

An asymptomatic 65-year-old man.An asymptomatic 65-year-old man.

CT scan Shaded-surface-display image

An asymptomatic 65-year-old man.An asymptomatic 65-year-old man.

ManagementManagement

Indications for surgical treatment Persistent or recurrent pain Hemodynamic instability Rapidly expanding aortic diameter.

Suggest surgical intervention with grafting of the affected area is the treatment of choice.

Murgo et alMurgo et al : surgical repair of the descending thoracic aorta is frequently complicated by respiratory disease, renal insufficiency, or spinal ischemia.

ManagementManagement

Harris et al.Harris et al. Immediate surgical treatment is not always

required. Few patients developed aortic dissection

or aortic rupture during follow-up. Most patients with penetrating

atherosclerotic ulcers are at high risk for surgical intervention.

ManagementManagement

Hayashi et al.Hayashi et al. Because could not predict rupture from the early

imaging findings. Should initially treated aggressively. Monitored clinical and radiologic data carefully during

the 1st month after onset. Surgical treatment may become necessary in

Evidence of intramural hematoma expansion, Signs of impending rupture Inability to control pain Blood pressure changes.

Relationship between Penetrating Relationship between Penetrating Atherosclerotic Ulcer and Aortic DissectionAtherosclerotic Ulcer and Aortic Dissection

Relationship between Penetrating Relationship between Penetrating Atherosclerotic Ulcer and Aortic DissectionAtherosclerotic Ulcer and Aortic Dissection

ConclusionsConclusions

Hayashi et al.Hayashi et al. Differentiation of penetrating atherosclerotic ulcer

from other causes of aortic disease such as aortic dissection, aortic aneurysm, and spontaneous aortic rupture is difficult or impossible in some cases.

Because critical cases of penetrating atherosclerotic ulcer cannot be identified on the basis of initial imaging findings, careful follow-up is needed in affected patients, particularly duringthe 1st month after onset.