Imaging description

Penetrating atheromatous ulcer occurs when ulceration of an atherosclerotic plaque extends through the internal elastic lamina of the aortic wall. On CT, there is ulceration of the aortic wall that extends beyond the expected level of the intima with an overlying bulge in the outer aortic contour (Figures 43.1–43.3). There is usually extensive atherosclerotic disease at and adjacent to the site of ulceration. The arch and descending aorta are the most frequently affected sites. Penetrating ulcer can be categorized according to the Stanford classification for aortic dissection; type A lesions involve the ascending aorta, and type B lesions involve only the descending aorta. Acute expansion of a penetrating ulcer can lead to intramural hematoma. Penetrating ulcer, dissection, and intramural hematoma comprise the “acute aortic syndromes” [1–4].

Importance

The natural history of penetrating aortic ulcer is not entirely clear. Some progress to intramural hematoma, classic dissection, or rupture, while others are asymptomatic and stable. Progression to saccular pseudoaneurysm is common [5, 6]. Asymptomatic patients are generally managed conservatively, while involvement of the ascending aorta or hemodynamic instability are indications for surgical or endovascular intervention [4].