Penetrating Aortic Ulcer

Ulceration of an atherosclerotic plaque that breaks through the internal elastic lamina into the media, with a variable haematoma. It makes up about 2 to 7% of acute aortic syndromes.

• It occurs mostly in the mid to distal descending thoracic aorta (about 90%) and in the abdominal aorta, in men aged about 70 to 75 with hypertension, smoking, and severe, diffuse atherosclerosis. An aortic aneurysm is present in about a quarter to a half of patients, and an intramural haematoma often coexists.
• Course: pseudoaneurysm formation, rupture (about 7% overall and higher in symptomatic patients, up to 40% in some series), distal embolisation of atheroma, and rarely true dissection (the stiff atherosclerotic wall resists propagation). Asymptomatic ulcers often remain stable, while symptomatic ulcers are unstable.
• Features that predict progression: ulcer depth greater than 10 mm, neck width greater than 20 mm, associated intramural haematoma or pleural effusion, enlarging ulcer, persistent pain.

• Many are asymptomatic and found on imaging. Acute back or chest pain (sudden, severe), dysphagia, hoarseness, shock and haemothorax with rupture, blue toe syndrome and livedo from atheroembolism.
• Differential diagnosis: aortic dissection, intramural haematoma, acute coronary syndrome, pulmonary embolism, leaking aneurysm, pancreatitis, and asymptomatic atherosclerotic ulcers.
• Complications: pseudoaneurysm, rupture, distal embolisation, dissection, and aneurysm enlargement.

• CT angiography: a focal contrast filled outpouching in a calcified atheromatous aorta, thickened enhancing wall, possible haematoma, pleural effusion or periaortic haematoma. Measure ulcer depth and neck width.
• MRI and transoesophageal echocardiography for clarification. Chest X-ray: widened mediastinum or pleural effusion.
• ECG, troponin, D-dimer, creatinine, full blood count, lactate, lipids, and screening for atherosclerosis at other sites.

• Asymptomatic, incidental ulcer:
  • Blood pressure less than 130/80 mmHg and heart rate 60 to 70 beats/min: bisoprolol 2.5 to 10 mg daily, ramipril 2.5 to 10 mg daily, amlodipine 5 to 10 mg daily.
  • Atorvastatin 40 to 80 mg daily, aspirin 75 to 100 mg daily, smoking cessation.
  • Repeat CT angiography at 1, 3, 6 and 12 months, then yearly.
  • Intervene if depth is greater than 10 mm with a neck greater than 20 mm, the ulcer grows, a pseudoaneurysm forms, or an associated saccular aneurysm is greater than 55 mm.
• Symptomatic ulcer:
  • Admit to intensive care. Morphine 2 to 5 mg IV for pain. Control heart rate and pressure with esmolol 500 micrograms/kg IV over 1 minute then 50 to 300 micrograms/kg/min, or labetalol 20 mg IV then 20 to 80 mg every 10 minutes (maximum 300 mg), target heart rate 60 beats/min and systolic pressure 100 to 120 mmHg.
  • Intervene urgently for rupture, haemodynamic instability, persistent or recurrent pain despite medical therapy, pleural effusion, a growing ulcer, large pseudoaneurysm, or distal embolisation.
  • Thoracic endovascular aortic repair is preferred (technical success greater than 90%; 30-day mortality about 5 to 10% elective and about 25 to 40% in rupture). Open repair with graft replacement when anatomy is unsuitable (mortality about 15 to 25%). Hybrid repair for arch lesions.
  • Complications of stent grafting: stroke (about 3 to 5%), spinal cord ischaemia (about 3%; use cerebrospinal fluid drainage in high risk patients and keep mean arterial pressure at 80 mmHg or more), endoleak, retrograde dissection and access injury.
  • Embolisation: anticoagulation is avoided because it can worsen atheroembolism; use aspirin 75 to 100 mg daily and a statin.
• Long term: strict blood pressure control, statin, smoking cessation, and avoid fluoroquinolones.
• Special groups:
  • Elderly and frail: favour endovascular repair; accept observation with medical therapy where the lesion is small and stable.
  • Renal impairment: reduce contrast volume and hydrate; use ultrasound or MRI without gadolinium for follow up where possible.
  • Pregnancy: very rare; manage with labetalol and nifedipine, and avoid ACE inhibitors and ARBs.
• Red flags: new or worsening pain, hypotension, haemoptysis or haematemesis (rupture into airway or oesophagus), blue toes, new neurological deficit.
• Follow up: CT angiography at 1 month after intervention, 6 months and 12 months, then yearly; blood pressure and lipid review at every visit.