Laselle, Brooks

Stull, Peter

Walsh, Ryan

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Western Journal of Emergency Medicine

Penetrating Atherosclerotic Aortic Ulcer

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UC IrvineWestern Journal of Emergency Medicine: Integrating Emergency Care with Population HealthTitlePenetrating Atherosclerotic Aortic UlcerPermalinkhttps://escholarship.org/uc/item/4g3690ztJournalWestern Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 11(5)ISSN1936-900XAuthorsWalsh, RyanLaselle, BrooksStull, PeterPublication Date2010Copyright InformationCopyright 2010 by the author(s).This work is made available under the terms of a Creative Commons Attribution-NonCommercial License, available at https://creativecommons.org/licenses/by-nc/4.0/ Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaVolume XI, no. 5  :  December 2010 528 Western Journal of Emergency MedicineImages In emeRgenCy medICInePenetrating Atherosclerotic Aortic UlcerRyan Walsh, MDBrooks Laselle, MDPeter Stull, MD	 Madigan	Army	Medical	Center,	Department	of	Emergency	Medicine,	Tacoma,	WASupervising Section Editor: Sean	Henderson,	MDSubmission	history:	Submitted	July	12,	2010;	Accepted	July	16,	2010Reprints	available	through	open	access	at	http://escholarship.org/uc/uciem_westjem[West	J	Emerg	Med.	2010;11(5):528-529.]A 79-year-old female presented to the emergency department complaining of two weeks of dyspnea on exertion and heart palpitations. A computed tomography (CT) pulmonary angiogram was obtained to rule out pulmonary embolism, which was negative. An incidental finding of a penetrating atherosclerotic ulcer (PAU) of the descending aorta was reported (Figure 1). A focused bedside ultrasound of this structure was then performed (Figure 2). This patient was admitted to the hospital with a vascular surgery consultation and managed with blood pressure control. She was discharged home after a negative work-up for her dyspnea with vascular surgery follow up.DISCUSSIONPAU occurs due to ulceration of the intima layer of the aorta leading to exposure of the media. Up to 20% of patients will be asymptomatic on presentation; however, most patients complain of anterior chest or midscapular back pain.1 PAU is uniformly associated with hypertension and presents between the seventh and ninth decades of life.2 Ultrasound findings of PAU are based largely upon transesophageal echocardiography describing an asymmetric out pouching of the aortic wall with jagged edges and no intimal flap.3 In our experience the findings on bedside abdominal ultrasound of a descending PAU are similar to saccular aortic aneurysms and CT is helpful in differentiating these conditions. We believe this is the first description of PAU on bedside abdominal ultrasound in the literature. Management of ascending PAU is emergent surgical repair while descending PAU can be managed with tight blood pressure control and repeat imaging. PAU is a rare but serious clinical entity. While the rate of rupture is as high as 40% in one series of symptomatic patients, many reports suggest a much lower rate when PAU is an incidental diagnosis.4Address for Correspondence: Ryan	Walsh,	MD,	Madigan	Army	Medical	Center,	Department	of	Emergency	Medicine,	Bldg	9040	Fitzsimmons	Ave,	Tacoma,	WA.	98431.	Email:	rdub88@gmail.comConflicts of Interest: By	the	WestJEM	article	submission	agree-ment,	all	authors	are	required	to	disclose	all	affiliations,	funding	sources	and	financial	or	management	relationships	that	could	be	perceived	as	potential	sources	of	bias.	The	authors	disclosed	none.Figure 1.	Computed	tomography	image	depicting	the	lesion	in	the	descending	aorta.Figure 2.	Ultrasound	image	of	the	proximal	abdominal	aorta.Western Journal of Emergency Medicine 529 Volume XI, no. 5  :  December 2010The	views	expressed	herein	are	solely	those	of	the	authors	and	do	not	represent	the	official	views	of	the	Department	of	Defense	or	Army	Medical	Department.REFERENCES1.	 Coady	M,	Rizzo	J,	Elefteriades	J.	Pathologic	variants	of	thoracic	aortic	dissections.	Penetrating	atherosclerotic	ulcers	and	intramural	hematomas.	Cardio Clinic.	1999;17:637-572.	 Coady	M,	Rizzo	J,	Hammond	G,	et	al.	Penetrating	ulcer	of	the	thoracic	aorta:	What	is	it?	How	do	we	recognize	it?	How	do	we	manage	it?.	J Vasc Surg.	1998;27:1006-1016.3.	 Meredith	E,	Masani	N.	Echocardiography	in	the	emergency	assessment	of	acute	aortic	syndromes.	Eur J of Echocardiography.	2009;10:131-9.4.	 Hayashi	H,	Matsuoka	Y,	Sakamoto	I,	et	al.	Penetrating	atherosclerotic	ulcer	of	the	aorta:	imaging	features	and	disease	concept.	RadioGraphics.	2000;20:995-1005Atherosclerotic Aortic Ulcer Walsh et al.

Echocardiography in the emergency assessment of acute aortic syndromes.

Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas. Cardio Clinic.

Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept. RadioGraphics. 2000;20:995-1005 Atherosclerotic Aortic Ulcer Walsh et al.

Penetrating ulcer of the thoracic aorta: What is it? How do we recognize it? How do we manage it?. J Vasc Surg.

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Penetrating Atherosclerotic Aortic Ulcer

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