**4. Clinical presentation**

The risk factors and clinical presentation of penetrating aortic ulcers are similar yet differ‐ ent in some ways from intramural hematomas and aortic dissections. Similar to patients with intramural hematomas, patients with penetrating aortic ulcers tend to be elderly and are typically older than patients with aortic dissection. As with the other acute aortic syn‐ dromes, symptoms include severe chest pain or midscapular pain. An important differ‐ ence between penetrating aortic ulcers and aortic dissections is that the former tends to be focal disease with absent signs of malperfusion or branch vessel occlusion, whereas the latter can be extensive and present with aortic insufficiency or organ malperfusion. The atherosclerotic burden also tends to be the greatest in patients with penetrating aortic ulcers as compared to those with intramural hematomas or aortic dissections in whom the degree of atherosclerosis is variable.

In a study of 19 patients with penetrating aortic ulcers, common comorbidities included hypertension (95%), chronic obstructive pulmonary disease (63%), cardiac disease (42%), chronic renal insufficiency (26%), and diabetes mellitus (16%) [14]. This comorbidity pro‐ file was similar to that seen in patients with intramural hematomas. Patients with pene‐ trating aortic ulcers were found to have the highest rate of concomitant abdominal aortic aneurysms (42%).

A large series of 105 patients with penetrating aortic ulcers demonstrated similar results [15]. Moreover, patients tended to be elderly with an average age of 72 years, and most patients were males (70%) and symptomatic (75%). Common comorbidities included hypertension (92%), smoking (77%), coronary artery disease (46%), chronic obstructive pulmonary disease (24%), and chronic renal insufficiency (21%). Concomitant abdominal aortic aneurysms were found in 61% of patients, and 30% had a pleural effusion on presentation.
