The Management of Patients With Penetrating Aortic Ulcers: A Systematic Review

Vasc Endovascular Surg. 2021 Oct;55(7):730-740. doi: 10.1177/15385744211017110. Epub 2021 May 28.


Background: Penetrating aortic ulcers (PAUs) are an entity within acute aortic syndrome. They often remain undiagnosed and are found incidentally or when they become symptomatic. Management is currently guided by clinical judgment. This review aims to identify indications for treatment and inform management.

Methods: We searched PubMed for studies on the management of PAUs. The outcome measures were mortality, progression and resolution of symptoms.

Results: This review incorporates 27 studies involving 1356 patients with PAU. Data was available regarding symptoms for 1213 patients (494 symptomatic, 719 asymptomatic). Overall late mortality for PAUs was found to be higher than 30-day mortality. Early mortality was higher for symptomatic patients as compared to those with asymptomatic PAUs. Early mortality was lowest for PAUs treated with endovascular interventions (5%), followed by PAUs managed medically and highest following open surgical management. Indications for treatment included symptoms, progression/instability, aortic diameter >5 cm, concomitant aortic pathology or pleural effusion. 13% of patients managed conservatively at initial presentation demonstrated progression and were considered for intervention subsequently. 9% of patients required reintervention after initial endovascular surgery.

Conclusion: Endovascular treatment, if anatomically suitable, should be considered as first line treatment for symptomatic PAUs. Patients with asymptomatic PAUs, if associated with high-risk features such as PAU diameter >20 mm, PAU depth >10 mm, aortic diameter >42 mm, concomitant pathology, morphological change or an infective etiology, should also be considered for intervention. Small asymptomatic PAUs with no high-risk features may be managed conservatively but must undergo regular surveillance.

Keywords: PAU; asymptomatic; management; penetrating aortic ulcer.

Publication types

  • Systematic Review

MeSH terms

  • Aortic Diseases / diagnosis
  • Aortic Diseases / mortality
  • Aortic Diseases / therapy*
  • Cardiovascular Agents / adverse effects
  • Cardiovascular Agents / therapeutic use*
  • Clinical Decision-Making
  • Disease Progression
  • Endovascular Procedures* / adverse effects
  • Endovascular Procedures* / mortality
  • Humans
  • Risk Assessment
  • Risk Factors
  • Treatment Outcome
  • Ulcer / diagnosis
  • Ulcer / mortality
  • Ulcer / therapy*
  • Vascular Surgical Procedures* / adverse effects
  • Vascular Surgical Procedures* / mortality


  • Cardiovascular Agents