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Penetrating Atherosclerotic Ulcer

by Xiu Srithammasit on Dec 17, 2009

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Penetrating Atherosclerotic Ulcer

Penetrating Atherosclerotic Ulcer

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Penetrating Atherosclerotic Ulcer — Presentation Transcript

Penetrating Atherosclerotic Ulcer of the Aorta Imaging Features and Disease Concept Present by : Ekksit Srithammasit, MD RadioGraphics 2000; 20:995–1005 Hayashi et al, Department of Radiology, Nagasaki University School of Medicine,
Introduction
- Penetrating Atherosclerotic Ulcer
- an ulcerating atherosclerotic lesion that penetrates the elastic lamina and is associated with hematoma formation within the media of the aortic wall
- F irst described by Stanson et al in 1986 -
Table of Contents
- Disease Course
- Imaging Appearances
- Prognosis
- Management
- Relationship between Penetrating Atherosclerotic Ulcer and Aortic Dissection
Disease Course
Imaging Appearances
- Angiogram : CT : MRI
- Generally use spiral CT to evaluate aortic disease.
Imaging Appearances
- CT features of penetrating ulcers
- Vilacosta et al described as
Contrast-enhanced CT scan A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain.
- CECT : after conservative treatment at 14 and 35 days
- Surgical treatment was not attempted, and the patient died 36 days after onset with severe hematemesis due to an aortoesophageal fistula.
A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain.
Photograph of the autopsy specimen A 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain. Low-power photomicrograph
A 74- year-old man with sudden onset of chest pain. CECT Thoracic aortogram
A 74- year-old man with sudden onset of chest pain.
- Follow-up CT scans obtained 7 (b) and 21 (c) days after onset
- The patient underwent surgery, the results of which confirmed penetrating atherosclerotic ulcer.
A 73-year-old man with back pain.
- Over 5 years later, the patient remains asymptomatic and the penetrating atherosclerotic ulcer remains unchanged in size
CECT 48 hours later CECT 48 hours later Oblique sagittal cine MRI 3 months later
Imaging Appearances
- Typically involve the descending thoracic aorta but can also involve the abdominal aorta, which is sometimes more severely atherosclerotic.
- Multiple penetrating atherosclerotic ulcers may also be seen.
A 73-year-old man with back pain.
- The patient was treated conservatively.
CECT CECT 2 weeks CECT 2 years
A 73-year-old man with back pain.
- The patient was treated conservatively.
A 73-year-old man with back pain. Unenhanced CT scan CECT
A 73-year-old man with back pain. Follow-up contrast-enhanced CT scan obtained 2 weeks after onset
Prognosis
- Little is known about the natural history of penetrating atherosclerotic ulcer.
Although cases of penetrating atherosclerotic ulcer typically have many features in common the prognosis was different from case to case .
Prognosis
- In our experience
- Coady et al reported
Prognosis
- We occasionally encountered a saccular aneurysm, which seemed to be caused by a penetrating atherosclerotic ulcer.
- Although rupture or other life-threatening complications are rare, affected patients must be followed up because such complications can progress slowly.
An asymptomatic 65-year-old man. CT scan Shaded-surface-display image
An asymptomatic 65-year-old man.
Management
- Indications for surgical treatment
- Suggest surgical intervention with grafting of the affected area is the treatment of choice.
- Murgo et al : surgical repair of the descending thoracic aorta is frequently complicated by respiratory disease, renal insufficiency, or spinal ischemia.
Management
- Harris et al.
- Immediate surgical treatment is not always required.
- Few patients developed aortic dissection or aortic rupture during follow-up.
- Most patients with penetrating atherosclerotic ulcers are at high risk for surgical intervention.
Management
- Hayashi et al.
- Because could not predict rupture from the early imaging findings.
- Surgical treatment may become necessary in
Relationship between Penetrating Atherosclerotic Ulcer and Aortic Dissection
Relationship between Penetrating Atherosclerotic Ulcer and Aortic Dissection
Conclusions
- Hayashi et al.
- Differentiation of penetrating atherosclerotic ulcer from other causes of aortic disease such as aortic dissection, aortic aneurysm, and spontaneous aortic rupture is difficult or impossible in some cases.
- Because critical cases of penetrating atherosclerotic ulcer cannot be identified on the basis of initial imaging findings, careful follow-up is needed in affected patients, particularly duringthe 1st month after onset.