Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease

Abstract

Objectives: Increased utilization of computed tomography angiography (CTA) has increased the radiologic diagnosis of penetrating atherosclerotic ulcers (PAUs), which are defined as the ulceration of atherosclerotic plaque through the internal elastic lamina into the aortic media. However, the presentation, treatment indications, and natural history of this disease process remain unclear.

Methods: The radiology database at a single university hospital was searched retrospectively for the CTA diagnosis of PAU from January 2003 to June 2009. All scans were interpreted by a cardiovascular radiologist. Information on PAU characteristics and need for surgical repair due to PAU disease was collected. PAU stability or progression was assessed by follow-up CTA, if available. Only PAUs in the aortic arch, descending thoracic aorta, and abdominal aorta were included.

Results: Three hundred eighty-eight PAUs were diagnosed by CTA interpretation. PAU location was in the aortic arch in 27 (6.8%) cases, the descending thoracic aorta in 243 (61.2%) cases, and the abdominal aorta in 118 (29.7%) cases. Two hundred twenty-four (57.7%) PAUs were isolated (without saccular aneurysm or intramural hematoma); 108 (27.8%) PAUs had associated saccular aneurysms; and 56 (14.4%) PAUs had associated intramural hematoma. Rupture was present in 16 (4.1%) cases. Fifty (12.9%) PAUs underwent repair with thoracic endovascular aortic repair (TEVAR) (n = 30), endovascular aneurysm repair (EVAR) (n = 10), or open surgery (n = 10); primary indications for repair were saccular aneurysm (n = 26), rupture (n = 16), and persistent or recurrent symptoms (n = 8). Even if initially treated conservatively with resolution of pain, symptomatic PAU disease was more likely to require repair than asymptomatic PAU disease (36.2% vs 7.8%, P < .001). Follow-up CTA was available for 87 PAUs, 20 (23.0%) of which demonstrated radiographic disease progression at a mean follow-up of 8.4 ± 10.3 months. Symptomatic PAU disease was more likely to progress than asymptomatic disease (42.9% vs 16.7%, P = .029).

Conclusions: For PAUs diagnosed on CTA at a single institution, 4.1% were ruptured and 12.9% underwent repair. Close follow-up imaging appears to be indicated for PAUs, particularly in the case of symptomatic disease, which is more likely to require repair and to undergo radiographic progression.