Penetrating Atheromatous Ulcer

  • Ulceration of an atheromatous plaque that
    • extends deeply
      • through the intima and
      • into the aortic media
      • may result in  localized medial dissection
      • may extend into the adventitia to form a pseudoaneurysm
      • and is usually associated with a variable amount of hematoma
      • distinguishing between
        • aneurysm
        • dissection
        • ulceration  is sometimes
          • difficult,
      • CT
        •  focal ulcer with adjacent
        • subintimal hematoma and is often associated with
        • aortic wall thickening or enhancement
        • Pathogenesis of Penetrating Diseases of the Aorta and Acute Aortic Syndrome
          The lumen of the aorta with blood is demonstrated in red. The intima of the wall is the thin light pink layer just under the red luminal layer. The media or elastic layer is in teal, while the outer layer is a light yellow color
          This diagram in a illustrates the normal aortic wall
          Image b shows the development of a cholesterol plaque commonly associated with acute aortic syndrome.
          Courtesy Ashley Davidoff MD
          TheCommonVein.net

          Initially, atheromatous ulcers develop in patients with advanced atherosclerosis. At this stage, the lesions are usually asymptomatic and

        • lesion confined to the intimal layer
        • usually asymptomatic
      • Mural Hematoma
        Ashley Davidoff
        TheCommonVein.net

         

  • lesion progresses to the media
    • usually symptomatic
  • Progressive Mural Hematoma
    Ashley Davidoff
    TheCommonVein.net
    Penetrating Ulcer with Hematoma
    Penetrating ulcer in the descending descending thoracic aorta  (bright red ) with overlying hematoma (maroon)                                                                                                                    key words fx aortic ulcer   fx atherosclerosis atheroma fx penetrating ulcer
    acute aortic syndrome CTscan
    48363
    Courtesy Ashley Davidoff MD TheCommonVein.net
    Penetrating ulcer in the descending descending thoracic aorta with overlying hematoma                                                                                            key words fx aortic ulcer   fx atherosclerosis atheroma fx penetrating ulcer
    acute aortic syndrome CTscan
    Ashley Davidoff MD TheCommonVein.net

    Penetrating Ulcer with Hematoma
    Penetrating ulcer in the descending descending thoracic aorta with overlying hematoma in a patient with acute aortic syndrome
    Courtesy Ashley Davidoff MD
    TheCommonVein.net
  • 86 M with penetrating ulcer of the distal abdominal aorta associated with a hematoma
    Ashley Davidoff
    TheCommonVein.net
    86 M with penetrating ulcer of the distal abdominal aorta associated with a hematoma
    Ashley Davidoff
    TheCommonVein.net
    86 M with penetrating ulcer of the distal abdominal aorta associated with a hematoma
    Ashley Davidoff
    TheCommonVein.net
    87 year old male with penetrating ulcer and expanding hematoma
    in the descending descending thoracic aorta in a patient with acute aortic syndrome
    Courtesy Ashley Davidoff MD TheCommonVein.net
    Angiogram of an atherosclerotic ulcer in the descending thoracic aorta on angiography
    It is difficult to distinguish between an aneurysm of the aorta and ulcerated plaque
    Ashley Davidoff
    TheCommonVein.net

    May focally dissect

    Focal Dissection
    A small focal dissection with flowing blood is seen, and this can either thrombose or progress to a full dissection
    Ashley Davidoff
    Focal Dissection
    The penetrating ulcer can progress into the media and may have limited dissection due to the chronic inflammatory changes, including fibrosis in the media
    Ashley Davidoff
    TheCommonVein.net
    Limited Dissection .
    Superiorly the aorta is mildly aneurysmal but no evidence of dissection
    Ashley Davidoff MD
    TheCommonVein.net
    Limited Dissection .
    Note the “flap ” of the dissection is thicker than the intimal flap of the classical dissection
    Ashley Davidoff MD
    TheCommonVein.net
    Limited Dissection .
    Note the “flap ” of the dissection is thicker than the intimal flap of the classical dissection
    Ashley Davidoff MD
    TheCommonVein.net
    Inferiorly there is no evidence of dissection
    Ashley Davidoff MD
    TheCommonVein.net

     

     

    Dissection could be progressive

    Progressive Dissection
    Progressive dissection with flowing blood is seen, and this can either thrombose or progress to a full dissection
    Ashley Davidoff
    TheCommonVein.net
    Acute Aotic Dissection in A Young Patient
    In acute aortic dissecction, the event is usually in a younger patient without atherosclerotic disease and the associated inflammatory changes in the wall. Hence a small tear in the media can rapidly dissect antegrade or retrograde , with rentry points occurring
    Ashley Davidoff
    TheCommonVein.net
    This series of CT scans were taken 1 day apart. The patient presented with chest pain and the soft tissue changes around contrast filled aorta (a,b,c) suggested a chronic dissection, or an acute thrombosed dissection. 1 day later the non-contrast CT clearly reveals an acute thrombosed dissection (d,e,f) that started in the arch and extended along the descending thoracic aorta. The last series (g,h,i) enhance the non contrats study. A non contrast CT followed by contrast injection, is an important tchnique to optimally characterise acute changes in this clincal setting. 36865c code CVS aorta thoracic arch descending dissection hyperdense cresecent sign acute thrombosed dissection 36865c new
    Keywords:
    CVS aorta thoracic arch descending dissection hyperdense cresecent sign acute thrombosed dissection 36865c new

  • Advance to the adventitia and form an aneurysm or pseudoaneurysm
    Penetration to Adventitia
    Ashley Davidoff
    TheCommonVein.net
    Expanding ulcer extending into the adventitia
    Ashley Davidoff
    TheCommonVein.net
    Expanding ulcer extending into the adventitia
    Ashley Davidoff
    TheCommonVein.net
    Expanding ulcer extending into the adventitia It is difficult to distinguish between an aneurysm of the aorta and expanding ulcerated plaque
    Ashley Davidoff
    TheCommonVein.net

     

  • Rupture
  • Rupture into the Mediastinum
    Ashley Davidoff
    TheCommonVein.net

     

    90 year old male with ulcerated plaque with rupture
    Courtesy Ashley Davidoff MD TheCommonVein.net

    2nd Case

    Ulcerated Plaque with Focal Dissection and Rupture into the Mediastinum
    Courtesy Ashley Davidoff MD TheCommonVein.net
    Rupture                                                                                                                                                       Rupture into the mediastinum (red arrow ) and complicated by a ipsilateral hemothorax (pink arrow)
    Ashley Davidoff
    TheCommonVein.net
    The focal disection (yellow arrow) into the wall and mediastinum (red arrow ) and complicated by a hemothorax (yellow arrow)
    Ashley Davidoff TheCommonVein.net
    Hemothorax with clot in the left pleural space
    Ashley Davidoff
    TheCommonVein.net
    Hemothorax with clot in the left pleural space
    Ashley Davidoff
    TheCommonVein.net

    Penetrating Ulcer with Rupture
    17529c01 artery descending thoracic aorta abdominal aorta dx rupture pseudoaneurysm ulcerating plaque mural hematoma ruptured through aortic wall hemorrhage hematoma retroperitoneum CTscan Courtesy Ashley Davidoff MD Ashley Davidoff MD

 

  • Magnetic resonance imaging
    • superior to conventional CT in
    • differentiating
      • acute intramural hematoma from
      • atherosclerotic plaque and chronic intraluminal thrombus

Links and References

Cooke JP et al The Penetrating Ulcer

 

TCV

Acute Aortic Syndrome

Atherosclerosis Pathogenesis

Ulcerated Plaque