**2. Pathophysiology**

Acute aortic syndromes are a group of disease entities that include penetrating aortic ulcers in addition to aortic dissections and intramural hematomas. Aortic dissections are defined by a tear of the intima that results in passage of blood and separation of the intimal and medial or adventitial layers of the vessel wall (Figure 1) [4]. This typically occurs in patients with cystic medial necrosis or medial degeneration. This creates a false lumen, and propagation of the tear either antegrade or retrograde can result in aortic valve insufficiency, cardiac tamponade, and/ or organ malperfusion [5]. Intramural hematomas are caused by rupture of the vaso vasorum. This leads to hemorrhage within the aortic media, and can subsequently lead to rupture of the aortic wall or inward disruption of the intima with resultant secondary aortic dissection [6,7].

As the name suggests, penetrating aortic ulcers arise from atheromatous plaques that ulcerate, causing disruption of the internal elastic lamina [6]. Erosion into the medial layer can lead to development of an intramural hematoma or dissection, complications that can eventually lead to pseudoaneurysm formation or aortic rupture. Penetrating aortic ulcers tend to occur in patients with advanced atherosclerosis. Furthermore, they can occur in isolation or in multiples

© 2013 Kilic and Kilic; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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

Penetrating Aortic Ulcers http://dx.doi.org/10.5772/54107 377

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

The diagnosis of penetrating aortic ulcers relies first upon a thorough history and physi‐ cal examination. The typical patient is elderly with a history of hypertension. As men‐ tioned previously, these patients can also have a history of coronary artery disease, chronic obstructive pulmonary disease, renal disease, and tobacco use. They typically present with anterior chest or midscapular pain. Similar to aortic dissections, those with anterior chest pain usually have ascending aortic involvement and those with back pain typically have descending aortic involvement. The differential diagnosis with this typical presentation includes acute coronary syndrome, aortic aneurysm, aortic dissection, intra‐

Physical examination should initially include a review of airway, breathing, and circulation to ensure that the patient is stable. Murmurs indicative of aortic insufficiency typically reflect aortic dissection as opposed to isolated penetrating ulcers, which are focal in nature. Similarly, signs of malperfusion such as neurologic deficits, acute renal insufficiency, visceral vessel compromise, or limb pain with pulse deficit usually occur with dissection as opposed to isolated penetrating aortic ulcers. It is important to note, however, that penetrating aortic ulcers and aortic dissections can occur concomitantly, and therefore, the presence of these signs on physical examination does not exclude a diagnosis of penetrating aortic ulcer. Penetrating aortic ulcers may also be discovered incidentally in asymptomatic patients with imaging

Radiological imaging is essential to the diagnosis of penetrating aortic ulcers given its similarities to other acute aortic syndromes with respect to clinical presentation. A plain chest roentgenogram is frequently obtained in patients presenting with these symptoms and may

found in 61% of patients, and 30% had a pleural effusion on presentation.

aneurysms (42%).

**5. Diagnosis**

**5.1. History and physical examination**

mural hematoma, and pulmonary embolism.

performed for other indications.

**5.2. Diagnostic modalities**

**Figure 1.** Acute aortic syndromes include aortic dissections, penetrating aortic ulcers (PAU), and intramural hemato‐ mas (IMH), each with different pathophysiologies. Aortic dissections are defined by a tear in the intima and separation of the intimal and medial or adventitial layers. Penetrating aortic ulcers result from lesions that ulcerate and disrupt the internal elastic lamina. Intramural hematomas can arise from penetrating aortic ulcers, or can occur in isolation after disruption of the vaso vasorum (from Reference 4 – permission granted).

[8]. Most commonly, penetrating aortic ulcers affect the descending thoracic aorta and less commonly the aortic arch, abdominal aorta, or ascending aorta [9].
