Penetrating atherosclerotic aortic ulcer: Difference between revisions
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{{CMG}} | {{CMG}} | ||
__NOTOC__ | __NOTOC__ | ||
'''Associate Editor-In-Chief:''' {{CZ}} | '''Associate Editor-In-Chief:''' {{Sahar}} {{CZ}} | ||
==Overview== | ==Overview== | ||
Penetrating atherosclerotic aortic ulcer is ulceration of atheromatous plaque that has eroded the inner, elastic layer of the aortic wall, reached the medial layer, and produced a hematoma in the media. | Penetrating atherosclerotic aortic ulcer is ulceration of atheromatous plaque that has eroded the inner, elastic layer of the aortic wall, reached the medial layer, and produced a hematoma in the media. | ||
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There is insufficient evidence to recommend routine screening for penetrating atherosclerotic aortic ulcer. | There is insufficient evidence to recommend routine screening for penetrating atherosclerotic aortic ulcer. | ||
==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
*Penetrating atherosclerotic aortic ulcer starts with the progressive increase in aortic size with subsequent aneurysm formation.<ref name="HayashiMatsuoka2000">{{cite journal|last1=Hayashi|first1=Hideyuki|last2=Matsuoka|first2=Yohjiro|last3=Sakamoto|first3=Ichiro|last4=Sueyoshi|first4=Eijun|last5=Okimoto|first5=Tomoaki|last6=Hayashi|first6=Kuniaki|last7=Matsunaga|first7=Naofumi|title=Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept|journal=RadioGraphics|volume=20|issue=4|year=2000|pages=995–1005|issn=0271-5333|doi=10.1148/radiographics.20.4.g00jl01995}}</ref><ref name="NathanBoonn2012">{{cite journal|last1=Nathan|first1=Derek P.|last2=Boonn|first2=William|last3=Lai|first3=Eric|last4=Wang|first4=Grace J.|last5=Desai|first5=Nimesh|last6=Woo|first6=Edward Y.|last7=Fairman|first7=Ronald M.|last8=Jackson|first8=Benjamin M.|title=Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease|journal=Journal of Vascular Surgery|volume=55|issue=1|year=2012|pages=10–15|issn=07415214|doi=10.1016/j.jvs.2011.08.005}}</ref> | |||
*If left untreated, patients with penetrating atherosclerotic aortic ulcer may progress to develop an intramural hematoma, pseudoaneurysm, or even aortic rupture, or an acute aortic dissection. | |||
If left untreated, | *Prognosis is generally poor and even worse than that of aortic dissection. | ||
Prognosis is generally poor | |||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Study of Choice=== | ===Diagnostic Study of Choice=== | ||
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*[http://goldminer.arrs.org/search.php?query=Penetrating%20atherosclerotic%20aortic%20ulcer Goldminer: Penetrating atherosclerotic aortic ulcer] | *[http://goldminer.arrs.org/search.php?query=Penetrating%20atherosclerotic%20aortic%20ulcer Goldminer: Penetrating atherosclerotic aortic ulcer] | ||
==References== | ==References== | ||
{{Reflist|2}} | |||
* [http://radiographics.rsnajnls.org/cgi/content/abstract/23/suppl_1/S93 Eva Castañer, Marta Andreu, Xavier Gallardo, Josep Maria Mata, María Ángeles Cabezuelo, and Yolanda Pallardó. CT in Nontraumatic Acute Thoracic Aortic Disease: Typical and Atypical Features and Complications. RadioGraphics 2003 23: S93-110S.] | * [http://radiographics.rsnajnls.org/cgi/content/abstract/23/suppl_1/S93 Eva Castañer, Marta Andreu, Xavier Gallardo, Josep Maria Mata, María Ángeles Cabezuelo, and Yolanda Pallardó. CT in Nontraumatic Acute Thoracic Aortic Disease: Typical and Atypical Features and Complications. RadioGraphics 2003 23: S93-110S.] | ||
{{Circulatory system pathology}} | {{Circulatory system pathology}} | ||
Revision as of 21:51, 31 December 2019
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: Sahar Memar Montazerin, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]
Overview
Penetrating atherosclerotic aortic ulcer is ulceration of atheromatous plaque that has eroded the inner, elastic layer of the aortic wall, reached the medial layer, and produced a hematoma in the media.
Historical Perspective
Classification
There is no established system for the classification of penetrating atherosclerotic aortic ulcer.
Pathophysiology
The exact pathogenesis of penetrating atherosclerotic aortic ulcer is not fully understood.
Causes
Penetrating atherosclerotic aortic ulcer may be caused by [cause1], [cause2], or [cause3].
Differentiating Penetrating atherosclerotic aortic ulcer from Other Diseases
Penetrating atherosclerotic aortic ulcer must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
Epidemiology and Demographics
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
Unlike typical aortic dissection, penetrating atherosclerotic ulcers most often occur in elderly patients with severe underlying atherosclerosis.
Risk Factors
Common risk factors in the development of penetrating atherosclerotic aortic ulcer include old age, smoking history, male gender, hypertension, coronary artery disease, and chronic obstructive pulmonary disease.[1][2]
Screening
There is insufficient evidence to recommend routine screening for penetrating atherosclerotic aortic ulcer.
Natural History, Complications, and Prognosis
- Penetrating atherosclerotic aortic ulcer starts with the progressive increase in aortic size with subsequent aneurysm formation.[2][3]
- If left untreated, patients with penetrating atherosclerotic aortic ulcer may progress to develop an intramural hematoma, pseudoaneurysm, or even aortic rupture, or an acute aortic dissection.
- Prognosis is generally poor and even worse than that of aortic dissection.
Diagnosis
Diagnostic Study of Choice
- Table below provides a comparison of diagnostic imaging studies for the diagnosis of penetrating atherosclerotic aortic ulcer:[4]
| Location | Diagnostic Modality | Diagnostic Value |
| Penetrating atherosclerotic aortic ulcer |
| |
|
| |
|
| |
|
|
- Contrast-enhanced CT imaging is the diagnostic study of choice for diagnosis of penetrating atherosclerotic aortic ulcer.
History and Symptoms
Physical Examination
Laboratory Findings
Imaging
Echocardigraphy
- Tansesophageal echocardiography has been approved to be sensitive and specific for the diagnosis of aortic diseas.[5]
CT Scan
- CT scan imaging with intravenous contrast is the diagnostic study of choice for diagnosis of penetrating atherosclerotic aortic ulcer.[2]
- Findings suggestive of penetrating atherosclerotic aortic ulcer include a localized ulcer passing from intima into aortic wall or contrast leak through a calcified plaque.
- It usually affects mid to distal third of descending aorta.
- Ulcer is usually defined by focal thickening or enhancement of aortic wall.
MRI
- MRI study is superior to conventional CT scan in the diagnposis of penetrating atherosclerotic aortic ulcer.[6]
- Finding suggestive of the diagnosis includes a well-defined ulcer with flow void phenomenon on T1 images.
Treatment
Medical Therapy
As for type B typical aortic dissection, the most widespread treatment for penetrating atherosclerotic ulcers is medical therapy.
Surgery
Surgery is performed in patients who have hemodynamic instability, persistent pain, aortic rupture, distal embolization, or rapid enlargement of the aortic diameter (surgical repair of a penetrating atherosclerotic ulcer is generally more complex and extensive than surgical repair of type B typical aortic dissection).
Primary Prevention
There are no established measures for the primary prevention of penetrating atherosclerotic aortic ulcer.
Secondary Prevention
There are no established measures for the secondary prevention of penetrating atherosclerotic aortic ulcer.
Guideline
2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)[4]
| Recomendacations | Class | Level |
|---|---|---|
| "In all patients with PAU, medical therapy including pain relief and blood pressure control is recommended." | I | C |
| "In the case of Type A PAU, surgery should be considered." | IIa | C |
| "In the case of Type B PAU, initial medical therapy under careful surveillance is recommended." | I | C |
| "In uncomplicated Type B PAU, repetitive imaging (MRI or CT) is indicated." | I | C |
| "In complicated Type B PAU, TEVAR should be considered." | IIa | C |
| "In complicated Type B PAU, surgery may be considered." | IIb | C |
Examples
See Also
External Links
References
- ↑ Coady, Michael A.; Rizzo, John A.; Elefteriades, John A. (1999). "PATHOLOGIC VARIANTS OF THORACIC AORTIC DISSECTIONS". Cardiology Clinics. 17 (4): 637–657. doi:10.1016/S0733-8651(05)70106-5. ISSN 0733-8651.
- ↑ 2.0 2.1 2.2 Hayashi, Hideyuki; Matsuoka, Yohjiro; Sakamoto, Ichiro; Sueyoshi, Eijun; Okimoto, Tomoaki; Hayashi, Kuniaki; Matsunaga, Naofumi (2000). "Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept". RadioGraphics. 20 (4): 995–1005. doi:10.1148/radiographics.20.4.g00jl01995. ISSN 0271-5333.
- ↑ Nathan, Derek P.; Boonn, William; Lai, Eric; Wang, Grace J.; Desai, Nimesh; Woo, Edward Y.; Fairman, Ronald M.; Jackson, Benjamin M. (2012). "Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease". Journal of Vascular Surgery. 55 (1): 10–15. doi:10.1016/j.jvs.2011.08.005. ISSN 0741-5214.
- ↑ 4.0 4.1 Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ (November 2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur. Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.
- ↑ Sommer T, Fehske W, Holzknecht N, Smekal AV, Keller E, Lutterbey G, Kreft B, Kuhl C, Gieseke J, Abu-Ramadan D, Schild H (May 1996). "Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging". Radiology. 199 (2): 347–52. doi:10.1148/radiology.199.2.8668776. PMID 8668776.
- ↑ Harris, James A.; Bis, Kostaki G.; Glover, John L.; Bendick, Phillip J.; Shetty, Anil; Brown, O.William (1994). "Penetrating atherosclerotic ulcers of the aorta". Journal of Vascular Surgery. 19 (1): 90–99. doi:10.1016/S0741-5214(94)70124-5. ISSN 0741-5214.