CASE 5584 Published on 26.08.2008

Penetrating ulcer of descending thoracic aorta

Section

Chest imaging

Case Type

Clinical Cases

Authors

Voultsinou D., Voultsinos V., Krikis P., Papadopoulos T., Kalpakidis V

Patient

70 years, male

Download as PDF Print Show related cases Notify admin

Clinical History

A 70 year old male, evaluated for known thoracic aortic aneurysm On clinical examination there were no suspicious signs or symptoms. The patient underwent a plain film and computed tomography examination.

Imaging Findings

A 70 year old male was evaluated for a known thoracic aorta aneurysm. On clinical examination there were no suspicious signs or symptoms. The patient underwent a plain film which depicted a dilated thoracic aorta. Computed tomography examination showed a focal ulceration of descending thoracic aorta, with associated intramural hematoma. The imaging findings were compatible with penetrating atherosclerotic ulcer.

Discussion

Penetrating atherosclerotic ulcer of the aorta is a distinct pathologic entity^{1.2, 3} defined as an atherosclerotic lesion with ulceration, which may have a clinical presentation that mimics aortic dissection. It occurs in elderly patients with advanced atherosclerotic disease. Typically penetrating ulcer occurs,^{1, 2, 3} in the middle or distal third of the thoracic aorta or upper abdominal aorta. They rarely are seen in the ascending aorta, where rapid blood flow from the left ventricle provides protection against atherosclerosis. Concomitant atherosclerotic aneurysms of the abdominal aorta are seen. It represents an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the media of the aortic wall. Involvement of the media can sometimes be complicated by aneurysmal dilatation or more rarely rupture^1.2.3. The four stages in the formation of penetrating atherosclerotic ulcer are a) aortic atheroma, b) intimal plaque ulceration contained in intima c) medial hematoma with potential adventitial false aneurysm d) and transmural rupture¹. Some authors have
theorized that most saccular aneurysms are caused by penetrating atherosclerotic ulcers ¹. CT features include a focal ulcer with adjacent subintimal hematoma Penetrating atherosclerotic ulcer can be differentiated from aortic dissection by means of (a) the extensive atherosclerotic disease and ectasia in penetrating atherosclerotic ulcer and (b) the lack of compression of the aortic lumen in elderly persons with penetrating atherosclerotic ulcer. Treatment of penetrating atherosclerotic ulcer is medical therapy. Surgery is performed in patients who have hemodynamic instability, persistent pain, aortic rupture, distal embolization or rapid enlargement of aortic diameter. It is important to notice that surgical repair of penetrating ulcer is more complex and extensive that type B dissecting aneurysm. Aortic grafting for penetrating atherosclerotic ulcer may be associated with higher morbidity because of greater compromise of spinal cord during blood supply surgery.

Differential Diagnosis List

Penetrating atherosclerotic ulcer of descending aorta

Final Diagnosis

Penetrating atherosclerotic ulcer of descending aorta

References

[1] E. Castaner, MD, M. Andreu, MD, X. Gallardo, MD, J. M.Mata, MD, PhD, M. A. Cabezuelo, MD and Y. Pallard　, MD. CT in Nontraumatic Acute Thoracic Aortic Disease: Typical and Atypical Features and Complications1. Radiographics. 2003;23:S93-S110. (PMID: 14557505)

[2] P., MD, B. Bigoni, MD , J. Manning, MD , D. R. Aberle, MD , K. Brown, MD, . Hart, MD, and J. Goldin, MD, PhD. Pitfalls in the Diagnosis of Thoracic Aortic Dissection at CT Angiography1 Radiographics. 2000;20:309-320.). (PMID: 10715333)

[3] C. Sebastia, MD1, E. Pallisa, MD1, S. Quiroga, MD1, A. Alvarez-Castells, MD1, R. Dominguez, MD1 and A. Evangelista, MD.2 Aortic Dissection: Diagnosis and Follow-up with Helical CT. Radiographics. 1999; 19:45-60. (PMID: 9925391)

Case information