Penetrating Aortic Ulcer and Intramural Hematoma

Acute aortic syndrome is a spectrum of three overlapping clinical and anatomic diseases: penetrating aortic ulcers, intramural hematomas, and acute aortic dissections. All three entities are part of a disease spectrum, which is characterized by a disruption of the aortic media to a varying degree. Penetrating aortic ulcer, intramural hematoma, and aortic dissection can occur as isolated processes or can be found in association. Although the clinical presentations of the three conditions overlap to some extent, the diagnosis of each specific disease is largely based on specific imaging findings. All three entities are potentially life threatening, so prompt diagnosis and treatment are of paramount importance. Risk factors include hypertension, male sex, tobacco use, atherosclerosis, previous aortic operations, catheter-based interventions, bicuspid aortic valve, and connective tissue disorders. This review summarizes the clinical presentation, diagnosis, indications for repair, and endovascular strategies in patients with acute aortic syndromes. Tables outline early and late outcomes of contemporary clinical series of endovascular repairs of penetrating aortic ulcers and intramural hematomas. Figures show the overlapping features of acute aortic syndromes, progression of penetrating aortic ulcers, a large penetrating aortic ulcer in the proximal thoracic aorta (including representations before endovascular repair and after stent graft coverage), completion angiography demonstrating the patency of chimney and thoracic stent grafts, pre- and postoperative computed tomographic angiography after endovascular repair of a complicated penetrating aortic ulcer, and the Stanford and DeBakey classification systems. This review contains 8 figures, 4 tables, and 73 references.