Penetrating Aortic Ulcers

What To Report

Definition A penetrating aortic ulcer is disruption of an atherosclerotic plaque with blood penetrating into or through the aortic wall.

Report

Location by aortic segment and whether the finding is thoracic, abdominal, or both.
Ulcer width/depth when measurable and the total aortic diameter at that level.
Associated intramural hematoma, focal dissection, pseudoaneurysm, saccular aneurysm, or periaortic hematoma.
Prior comparison, interval change, and whether symptoms are known from the clinical history.

Why it matters

Natural history is variable and can be unpredictable.
PAU may progress to intramural hematoma, focal dissection, pseudoaneurysm, rupture, or may remain stable.
Stability should be based on direct comparison at the same anatomic level.

Asymptomatic PAU

Typical next step Asymptomatic penetrating aortic ulcers are commonly followed with annual imaging when no high-risk features are present.

Surveillance

CTA or MRA is usually used for follow-up.
Use the same modality and technique when feasible.
Report whether the ulcer and adjacent aortic diameter are stable, enlarged, or smaller.
Include the oldest comparable study when estimating long-term change.

Lower concern pattern

Small, incidental, stable PAU.
No intramural hematoma, pseudoaneurysm, periaortic hematoma, or rapid enlargement.
No symptoms attributable to the aorta.

Escalate

Changing or symptomatic Symptomatic or enlarging PAU warrants closer follow-up and consideration of vascular surgery or endovascular consultation.

Concerning features

Pain or other symptoms attributable to the involved aortic segment.
Increasing ulcer depth or width, enlarging adjacent aortic diameter, or new saccular morphology.
Intramural hematoma, focal dissection, pseudoaneurysm, leak, rupture, or periaortic hematoma.
Pleural, mediastinal, retroperitoneal, or periaortic blood/fluid that raises concern for acute aortic syndrome.

Impression habits

State "penetrating aortic ulcer" explicitly when the morphology is convincing.
Flag symptomatic, changing, or high-risk morphology in the impression.
Tie follow-up or referral recommendation to the concerning feature.