Penetrating Atherosclerotic Ulcers of the Infrarenal Aorta: Life-threatening Lesions

To analyze the incidence, clinical features, natural history, and treatment of penetrating atherosclerotic ulcers (PAU) of the abdominal aorta. From January 2000 to June 2003, an abdominal PAU was diagnosed at our institution in eight patients (seven men, one woman; mean age 70 year). These eight cases were analyzed together with 38 additional cases found in a review of the literature (total 46 cases). Occurring at an incidence of approximately 1%, abdominal PAU are less common than thoracic PAU. Seventy percent of cases are symptomatic: pain 52.5% ( n=21), acute lower limb ischemia due to distal embolism 12.5% ( n=5), shock 5% ( n=2). Diagnosis is usually made by CT (66%) ( n=26) that demonstrates a PAU in 35% ( n=16) of cases, a subadventitial pseudoaneurysm in 28% ( n=13), and rupture in 37% ( n=17). An intramural hematoma (IMH) is observed in 9% ( n=4) of cases. There were no cases of aortic dissection in this series. Calcifications of the abdominal aorta were frequent (56%) ( n=26); while intra-aortic mural thrombus was found in 24% of cases ( n=11), and 46% of patients ( n=21) had an associated aneurysm. Twelve patients were treated medically while 34 underwent surgery (one postoperative death). Review of the literature and this series suggests that PAU of the abdominal aorta is a life-threatening lesion, the main risk being rupture. Surgical management is recommended owing to its low morbidity and mortality.