PENETRATING ATHEROSCLEROTIC ULCERS OF THE AORTA

Purpose: This study investigates the natural history and optimal imaging modality of penetrating atherosclerotic ulcers of the aorta. Methods: We reviewed our experience with 29 penetrating ulcers in 18 patients. Computed tomography (17 patients), magnetic resonance imaging (nine patients), and aortography (five patients) were used for diagnosis and follow-up. Patients were typically elderly (average age 74 years) and had hypertension and coronary artery disease. Ulcers were most common in the distal descending thoracic aorta (31%) and were characterized by a discrete ulcer crater (100%) and thickened aortic wall (89%). Modes of presentation included chest or back pain in four patients, distal embolization in two patients, and abnormal chest radiography results in one; the remaining were incidental findings. Results: Follow-up was available in ten patients with 17 ulcers from 1 to 7 years. Recurrent pain occurred in two patients, recurrent embolization occurred in one patient, and seven patients remained symptom free. Progression to saccular pseudoaneurysm occurred in five ulcers, and fusiform aneurysm occurred in two ulcers. Two ulcers were associated with an increase in aortic diameter, and nine ulcers did not change. There were no cases of aortic dissection or rupture in the follow-up period. There were no deaths and only one patient underwent resection. Conclusion: The natural history of penetrating atherosclerotic ulcers is one of progressive aortic enlargement, with saccular and fusiform aneurysms the result if follow-up is sufficient. Aortic dissection, aortic rupture, and embolization can also occur but are less common. Contrast-enhanced computed tomography is the primary imaging modality.