Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wall.
It has reached the media and produced a hematoma within the media.

Brief facts:

• Patients with severe systemic atherosclerosis
• Rarely rupture, yet worse prognosis due to extensive atherosclerosis which causes organfailure (e.g. acute myocardial infarction)
• Cause of most saccular aneurysms
• Located in arch and descending aorta
• Often multiple (therefore surgical treatment difficult, mostly treated medically)

What the clinician needs to know

• Type A or Type B
• Single or multiple
• Associated IMH (if not present, be cautious to mention PAU, clinical symptoms might not be caused by PAU, which is probably stable)
• Possibility of endovascular treatment

typical illustration of PAU, focal outpouchings of contrast, separating extensive intimal calcifications

Imaging features

• Extensive atherosclerosis with severe intima calcifications and atherosclerotic plaques
• Focally displaced and separated intimacalcifications
• Crater and/or contrast extravasation
• -Focal IMH, longitudinal spread limited by mediafibrosis
• Possibly enhancing aortic wall

Complications

The complications of a Penetrating Atherosclerotic Ulcer include:

• Saccular aneurysm formation
• Compression of nearby structures
• Rupture

However most patients have a poor prognosis because of generalized atherosclerosis leading to diffuse organ failure.