Ross
413 lines
38 KiB
Markdown
413 lines
38 KiB
Markdown
---
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title: "Penetrating Atherosclerotic Ulcer"
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docid: "63f6cba2-2200-456a-8d03-ac3111e420c8"
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authors:
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- key: "9ad9af12-61a1-44d6-af52-0ee1f38eb298"
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value: "Davis Vigneault, MD, DPhil"
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value: "Dominik Fleischmann, MD"
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- key: "10bb95ac-a27a-4ebe-833b-e59fea07734b"
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value: "Santiago Mart\u00ednez-Jim\u00e9nez, MD, FACR"
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breadcrumbs:
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name: "Cardiac"
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slug: "cardiac"
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treeNodeId: "fa90100b-619c-430e-8074-b5b9789bab39"
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "5c92cf4f-e9d5-4059-9c13-22255c51c121"
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name: "Aorta"
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slug: "aorta"
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treeNodeId: "4d206a6b-1a82-467c-9199-0df25ab749d7"
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name: "Penetrating Atherosclerotic Ulcer"
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slug: "penetrating-atherosclerotic-ulcer"
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category: "Cardiac"
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documentVersionId: "412ad523-b2df-4d8e-a1cb-537301c9c463"
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imageCount: 28
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lastUpdated: "01/24/25"
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pageDescription: "Penetrating Atherosclerotic Ulcer"
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pageKeywords: "Cardiac, Diagnosis, Aorta, Penetrating Atherosclerotic Ulcer"
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pageTitle: "Penetrating Atherosclerotic Ulcer | STATdx"
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enhancedTitle: "Penetrating Atherosclerotic Ulcer"
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type: "DX"
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references: true
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ddx: true
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anatomy:
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cases: 1
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breadcrumbs:
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- "Cardiac"
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- "Diagnosis"
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- "Aorta"
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- "Penetrating Atherosclerotic Ulcer"
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---
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# KEY FACTS
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- ## Terminology
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- Ulceration of atherosclerotic plaque that penetrates internal elastic lamina into media with variable amount of intramural hematoma (IMH)
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- ## Imaging
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- NECT: Abnormal aortic contour if penetrating atherosclerotic ulcer (PAU) has penetrated beyond adventitia; possible IMH if acute
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- CTA: Contrast outpouching extending beyond expected depth of aortic intima ± IMH
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- MR: Similar sensitivity and findings to CTA, but less practical in emergent evaluation of acute aortic syndrome
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- ## Top Differential Diagnoses
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- Ulcerated atherosclerotic plaque (nonpenetrating ulcer)
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- Intimomedial disruptions in IMH (focal intimal disruption, intramural blood pool)
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- Chronic healed PAU
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- Mycotic pseudoaneurysm
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- ## Pathology
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- Stanford classification for aortic dissection
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- Type A: Ascending ± arch/descending aorta
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- Type B: Ascending **not** involved (only descending ± arch)
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- Variable IMH from erosion of vasa vasorum
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- Classification of AAS (Svensson)
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- Class I: Classical dissection
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- Class II: Intramural hematoma or hemorrhage
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- Class III: Subtle dissection without hematoma
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- Class IV: Penetrating aortic ulcer
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- Class V: Iatrogenic or traumatic dissection
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- ## Clinical Issues
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- Acute: Chest/back pain in thoracic aorta, abdominal/back/flank pain in abdominal aorta
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- Chronic: Common incidental finding, asymptomatic, never associated with IMH
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- Older adults (typically 7th decade or later), M > F
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- Risk factors: Hypertension, tobacco use, coronary artery disease, chronic obstructive pulmonary disease, and renal insufficiency
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- Concomitant aortic aneurysm is common
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- Acute PAU (symptomatic ± IMH) are more likely to progress to perforation or aortic rupture
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- Chronic healed PAU (asymptomatic without IMH) are unlikely to progress
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- Consider treatment if symptomatic, complicated, or large
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# TERMINOLOGY
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- ## Abbreviations
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- Penetrating atherosclerotic ulcer (PAU)
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- ## Definitions
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- Ulceration of atherosclerotic plaque penetrating through internal elastic lamina into media or beyond
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- Acute aortic syndrome (AAS): Clinical syndrome describing acute aortic pain syndrome (sharp, tearing, very abrupt chest or back pain) in contradistinction to acute coronary syndrome (more dull, pressure-like, gradual onset)
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- Most common pathologies resulting in symptoms of AAS are classic dissection, intramural hematoma (IMH), and PAU, but also include limited tears and rupturing thoracic aortic aneurysms
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- Traumatic aortic injuries and iatrogenic dissections (e.g., as complication of percutaneous intervention or associated with surgery) are usually **not** considered AAS (since they do not "present" with spontaneous acute symptoms), although they are acute pathologic entities
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- AAS is clinical pain syndrome, not specific pathology
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# IMAGING
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- ## General Features
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- ### Best diagnostic clue
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- Contrast extending beyond expected depth of intima in setting of atherosclerosis
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- ### Location
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- Most commonly involves mid- to distal descending thoracic aorta
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- Less commonly involves aortic arch and ascending or abdominal aorta
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- Patients with acute PAU commonly have chronic atherosclerotic ulcers and aneurysms
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- Sometimes > 1 PAU can be seen
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- ## Radiographic Findings
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- Chest radiography is insensitive and often normal
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- Pleural effusion is common when acute
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- May be helpful for identifying other causes of chest pain
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- ## CT Findings
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- ### NECT
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- ± focally abnormal aortic contour if PAU extends beyond adventitia
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- May be obscured by adjacent IMH
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- ± adjacent concentric or crescentic hyperattenuating intramural hematoma (IMH) (if acute)
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- Associated calcified atherosclerotic plaques
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- ### CTA
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- Intraluminal contrast extending beyond expected depth of intima; ± focal adjacent IMH if acute
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- Often better appreciated on NECT
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- Adjacent hemorrhage (i.e., contained rupture or pseudoaneurysm); may progress to aortic rupture
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- ## MR Findings
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- ### MRA
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- Similar findings and sensitivity to CTA, but is less cost-effective and less practical in emergent acute aortic syndrome (AAS) evaluation
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- ## Angiographic Findings
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- Conventional
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- Outpouching (ulcer) along descending thoracic aorta
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- Luminal irregularity from diffuse atherosclerotic plaque
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- ## Imaging Recommendations
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- ### Protocol advice
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- Obtain NECT before CTA to help identify IMH
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# DIFFERENTIAL DIAGNOSIS
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- ## Ulcerated Atherosclerotic Plaque
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- Ulceration confined to aortic intima; does not extend beyond expected depth of intima
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- These non-PAUs are extremely common and present in almost all individuals with advanced atherosclerotic disease
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- Ulcerated plaques (a.k.a. ruptured plaques) in side branches of aorta cause most of acute cardiovascular events
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- Myocardial infarct if in coronary arteries; stroke if in cerebral vasculature
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- ## Intimomedial Disruptions in Intramural Hematoma
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- Focal intimal disruption: > 0.3-cm orifice, representing isolated entry tear, more likely to progress
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- Additional terms used in literature include ulcer-like projection and isolated primary intimal tear
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- Intramural blood pool (IBP): < 0.3-cm orifice, representing avulsed branch vessel (therefore descending aorta only), more likely to spontaneously resolve
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- Additional terms used in literature include natural fenestrations, branch artery pseudoaneurysms, and focal puddles (corresponding to IBP)
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- Does not communicate with aortic lumen
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- ## Chronic Healed Penetrating Atherosclerotic Ulcer
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- Asymptomatic and no IMH = unlikely to progress
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- [Traumatic Aortic Injury](/document/traumatic-aortic-injury/e32745ac-4438-41cc-a44a-7106fbbfc657)
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- History of trauma/additional traumatic findings; not associated with atherosclerosis
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- Aortic isthmus (most common), diaphragmatic hiatus, or aortic root
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- [Mycotic Pseudoaneurysm](/document/mycotic-aneurysm/20616d0a-7e0b-48d9-9be9-1af29e3dd6da)
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- Clinical evidence of infection; not associated with atherosclerosis; can be morphologically similar to PAU
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- Manifestation of advanced atherosclerosis
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- Only very small fraction of atherosclerotic ulcers penetrate deeper than into thickened intima, into media of aorta or beyond
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- ### Associated abnormalities
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- Coexistent aortic aneurysms, coexisting nonpenetrating ulcers, or chronic (healed) PAUs
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- Location
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- Descending thoracic aorta is most commonly affected
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- ## Staging, Grading, & Classification
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- Stanford classification (for aortic dissection)
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- Type A: Ascending aorta
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- Type B: Aortic arch &/or descending aorta
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- ## Gross Pathologic & Surgical Features
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- Variable presence/degree of IMH
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- ## Microscopic Features
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- Disruption of internal elastic lamina and extension into media
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# CLINICAL ISSUES
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- ## Presentation
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- ### Most common signs/symptoms
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- Acute-onset sharp chest/back pain in thoracic aorta, abdominal/back/flank pain in abdominal aorta
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- Chronic: Often seen on imaging in patients with atherosclerosis; acute PAUs can heal, reendothelialize, and become chronic
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- In chronic phase, they can grow slowly over time and become saccular, eccentric aneurysms
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- Embolization of atheroma (uncommon): Atherosclerotic plaque ulceration can lead to atheroembolism into downstream vessels
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- Classic manifestation is "blue toe syndrome'" due to microembolic occlusion of small peripheral arteries
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- Atheroembolism is related to superficial plaque rupture, not to deep penetration, but these can coincide
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- ## Demographics
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- ### Epidemiology
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- M > F; PAU represents 2-7% of all AASs
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- Classic atherosclerosis risk factors, established atherosclerotic diseases
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- Associated concomitant diseases: Hypertension, tobacco use, coronary artery disease, cerebrovascular disease, peripheral artery disease, chronic obstructive pulmonary disease, and renal insufficiency; history of myocardial infarction, stroke, aortic aneurysms, peripheral artery disease
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- Concomitant aortic aneurysm is common
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- Age: Older adults (typically 7th decade or later)
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- ## Natural History & Prognosis
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- Evolution of PAU
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- Acute PAU (symptomatic ± IMH) can → aortic rupture
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- If associated with IMH, CT attenuation of mural thrombus decreases and becomes isodense to blood pool within 7-10 days on NECT
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- Chronic, healed PAUs are usually asymptomatic; they can remodel over time and grow gradually over years
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- They may become saccular aneurysms
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- High-risk features: Diameter ≥ 13-20 mm, depth ≥ 10 mm, significant growth, associated saccular aneurysm, or increasing pleural effusion
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- ## Treatment
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- Medical management if uncomplicated
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- Open or endovascular surgical intervention if complicated
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- Rupture (impending), malperfusion, uncontrollable pain/hypertension
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- Endovascular therapy is preferred over open surgical repair in anatomically suitable candidates
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b8b3e292-9b6b-4cb3-9d4d-f431e6d3c8c9
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## References
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# Selected References
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1. [Isselbacher EM et al: 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology joint committee on clinical practice guidelines. Circulation. 146(24):e334-482, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36322642%5Bpmid%5D)
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1. [DeCarlo C et al: Prognostication of asymptomatic penetrating aortic ulcers: a modern approach. Circulation. 144(14):1091-101, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34376058%5Bpmid%5D)
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1. [Ishizu K et al: Focal intimal disruption size at multidetector CT and disease progression in type B aortic intramural hematoma. Radiology. 301(2):311-9, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34374587%5Bpmid%5D)
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1. [Raptis CA et al: Intramural hematoma and focal intimal disruption: the importance of communication. Radiology. 301(2):320-1, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34374599%5Bpmid%5D)
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1. [Vilacosta I et al: Acute aortic syndrome revisited: JACC state-of-the-art review. J Am Coll Cardiol. 78(21):2106-25, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34794692%5Bpmid%5D)
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1. [Evangelista A et al: Penetrating atherosclerotic ulcer. Curr Opin Cardiol. 35(6):620-6, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32925190%5Bpmid%5D)
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1. [Bossone E et al: Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 39(9):739-49d, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29106452%5Bpmid%5D)
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1. [El Hassani I et al: Penetrating atherosclerosis aortic ulcer: a re-appraisal. Acta Chir Belg. 117(1):1-7, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=27593515%5Bpmid%5D)
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1. [Gutschow SE et al: Emerging Concepts In Intramural Hematoma Imaging. Radiographics. 36(3):660-74, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27163587%5Bpmid%5D)
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1. [Patatas K et al: Penetrating atherosclerotic ulcer of the aorta: a continuing debate. Clin Radiol. 68(8):753-9, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23541075%5Bpmid%5D)
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1. [Akin I et al: Penetrating aortic ulcer, intramural hematoma, acute aortic syndrome: when to do what. J Cardiovasc Surg (Torino). 53(1 Suppl 1):83-90, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22433727%5Bpmid%5D)
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1. [Bischoff MS et al: Penetrating aortic ulcer: defining risks and therapeutic strategies. Herz. 36(6):498-504, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21887528%5Bpmid%5D)
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1. [Vilacosta I et al: Acute aortic syndrome: a new look at an old conundrum. Postgrad Med J. 86(1011):52-61, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20065341%5Bpmid%5D)
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1. [François CJ et al: MRI of the thoracic aorta. Cardiol Clin. 25(1):171-84, vii, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17478245%5Bpmid%5D)
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1. [Hayashi H et al: Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept. Radiographics. 20(4):995-1005, 2000](http://www.ncbi.nlm.nih.gov/pubmed/?term=10903689%5Bpmid%5D)
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## Differential diagnosis
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### Aortic Intramural Abnormality
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DDX:75d7b37f-bc37-493b-8961-8b2a9001fb94
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### Dilated Aorta
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DDX:9daee273-f1e9-4cf9-a979-8990a9b82e40
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## Anatomy
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### Aortic Arch and Great Vessels
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Brain/ANATOMY:a7a252f0-2ac6-402a-8c87-cfce8adc799b
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### Vessels, Lymphatic System, and Nerves, Abdominal
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Gastrointestinal/ANATOMY:0c38fd49-88e7-4272-960f-b17a194ce0cc
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### Aorta and Inferior Vena Cava
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Ultrasound/ANATOMY:eed39e4d-478b-45d3-9406-1eace6e9eef1
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### Abdominal Aorta and Visceral Vasculature Anatomy
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Vasculature/ANATOMY:341c0af5-bfe8-4755-a401-39b7b9f2d9b9
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## Cases
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- {'cases': [{'authors': [{'key': '2cd036e9-d3d3-4b44-93f1-c0f8bf83ac5e', 'value': None}, {'key': 'd69a0534-8989-4b83-b19d-c3b640f22e53', 'value': 'Megan R. Saettele, MD'}, {'key': '2e78a4ff-418e-46f9-93e4-c6d95d960e35', 'value': 'Brandt C. Wible, MD'}], 'caseVersionId': '9fb96b0f-ca0f-4791-906a-b5842feee3d3', 'description': 'Unenhanced CT imaging of the abdomen was performed for clinical suspicions of a functional adrenal adenoma (#1-2). No such abnormality was found. However, a small left posterior outpouching from the infrarenal abnormal aorta was incidentally seen (white arrows, #1-2), this finding consistent with a small aortic ulcer.\n\nApproximately 1.5 years later, the patient began complaining of claudication. An abdominal aortic angiogram was subsequently performed (#3), and a frontal projection from this study demonstrates several focal outpouchings from the distal abdominal aorta (black arrows, #3). A coned-in sagittal image shows a large posterior ulceration from the abdominal aorta (black arrow, #4).\n\nComment: Aortic ulcerations (also known as penetrating atherosclerotic aortic ulcers) are associated with a relatively high rate of aortic rupture, particularly those greater than 2 cm in diameter or 1 cm in depth. The vast majority of these occur in the descending aorta, and multiple ulcers are not uncommon. Ulcerations with an intimal flap may be distinguished from focal aortic dissections on cross sectional imaging in that the flap extends across the length of the aorta in the latter. Antihypertensive medical therapy and close monitoring is the most common treatment course. For larger and/or deeper ulcers, surgical or endovascular therapy may be pursued.', 'history': 'Patient with a history of hypertension and atherosclerosis.', 'imagePoolId': '947416de-a16e-47b7-8319-3be51e8bc7a2', 'name': 'Abdominal aortic ulceration', 'teachingPoint': None, 'demographics': '75 Years old male'}], 'caseType': 'typical', 'name': 'TYPICAL'}
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## Images
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### Selected Images
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*PA chest radiograph in a patient with penetrating aortic ulcer (PAU) of the aortic arch shows a mediastinal mass <img src='img/arrows/WC.png'/> lateral to the aortic arch from associated hematoma and a left pleural effusion <img src='img/arrows/WO.png'/>. Note the aortic intimal calcification <img src='img/arrows/CS.png'/>.*
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*PA chest radiograph in a patient with penetrating aortic ulcer (PAU) of the aortic arch shows a mediastinal mass <img src='img/arrows/WC.png'/> lateral to the aortic arch from associated hematoma and a left pleural effusion <img src='img/arrows/WO.png'/>. Note the aortic intimal calcification <img src='img/arrows/CS.png'/>.*
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*Sagittal oblique CTA in the same patient shows extensive atherosclerosis of the aorta <img src='img/arrows/WS.png'/> with a small, penetrating ulcer <img src='img/arrows/BS.png'/> and a large focal mural hematoma <img src='img/arrows/WC.png'/>. PAUs are associated with a variable degree of intramural hematoma (IMH), either focal (as in this case) or diffuse.*
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*Axial CECT of the chest in a patient with PAU at the proximal ascending thoracic aorta shows an outpouching extending beyond the aortic wall <img src='img/arrows/CS.png'/>, adjacent atherosclerosis <img src='img/arrows/CC.png'/>, and bilateral pleural effusions <img src='img/arrows/CO.png'/>.*
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*Coronal oblique CECT in the same patient shows the relationship of PAU <img src='img/arrows/CS.png'/> with the ascending aorta and left coronary artery <img src='img/arrows/CC.png'/>. Location in the ascending aorta and acute chest pain are the most important factors that determine emergent treatment due to high risk of rupture.*
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*Axial NECT of the chest in a patient with PAU at the aortic arch with aortic rupture shows an anterior mediastinal mass due to mediastinal hematoma <img src='img/arrows/WS.png'/>, indicating rupture. Note that PAU can simulate the presence of an anterior mediastinal mass, and contrast remains critical for appropriate differentiation.*
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*Axial CTA of the chest in the same patient shows a large ulceration along the anterior proximal aortic arch <img src='img/arrows/WO.png'/> with surrounding mediastinal hemorrhage <img src='img/arrows/WS.png'/> and extensive atherosclerosis <img src='img/arrows/BS.png'/>.*
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*Sagittal oblique reformation in the same patient depicts the ulceration <img src='img/arrows/WS.png'/> and large pseudoaneurysm <img src='img/arrows/WO.png'/> along the proximal arch. Note extensive calcific atherosclerosis <img src='img/arrows/WC.png'/>.*
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*Volume-rendered CTA in the same patient shows the large pseudoaneurysm <img src='img/arrows/WC.png'/>, which is compressing the proximal left carotid artery <img src='img/arrows/WS.png'/>. Volume renderings may be helpful to thoracic surgeons for surgical planning.*
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*SSFP (left) and T1W (middle) MR images in a 67-year-old woman with chest pain and history of anaphylaxis with iodinated contrast shows a small PAU in the descending thoracic aorta <img src='img/arrows/CS.png'/> with surrounding IMH <img src='img/arrows/CO.png'/>. Angiogram prior to stent placement (right) shows the PAU <img src='img/arrows/WS.png'/>. (Courtesy S. Kligerman, MD.)*
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*CTA in a man with chest pain shows extensive atherosclerotic disease and a small PAU <img src='img/arrows/CS.png'/> with surrounding IMH <img src='img/arrows/CO.png'/>. (Courtesy S. Kligerman, MD.)*
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*Axial CECT of the chest in a patient with PAU at the descending thoracic aorta shows lobulation of the right lateral wall of the aorta <img src='img/arrows/CS.png'/> with a variable amount of adjacent IMH <img src='img/arrows/CC.png'/>. The most common location of PAU is the descending aorta, followed by the abdominal aorta, and, rarely, the ascending aorta.*
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*Coronal oblique CECT in the same patient shows focal outpouching <img src='img/arrows/CS.png'/> from PAU with a small amount of adjacent IMH <img src='img/arrows/CC.png'/>. Also note scattered atherosclerosis <img src='img/arrows/CO.png'/>.*
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*Axial NECT of the chest in a patient with IMH secondary to PAU shows crescentic hyperdensity <img src='img/arrows/WS.png'/> along the descending aorta, consistent with IMH. NECT is helpful in differentiating PAU with IMH from arteritis, which is not hyperdense.*
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*Sagittal CTA of the chest in a patient with IMH secondary to PAU shows a large, relatively shallow ulceration <img src='img/arrows/WC.png'/> extending beyond the expected aortic margin. Note also the aortic wall thickening <img src='img/arrows/BS.png'/> from IMH.*
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*Axial NECT (left) and CTA (right) in a patient with contained rupture of a descending aortic PAU show retrocrural hemorrhage <img src='img/arrows/WC.png'/> and atherosclerosis <img src='img/arrows/WO.png'/> with contrast <img src='img/arrows/WS.png'/> extending beyond the expected aortic margin.*
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*Axial CTA of the chest before (left) and after (right) treatment shows a PAU along the descending thoracic aorta <img src='img/arrows/BS.png'/>, which is excluded after placement of an endovascular stent <img src='img/arrows/BO.png'/>. Endovascular therapy has become the treatment of choice whenever feasible.*
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### Additional Images
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*Coronal CECT shows atherosclerosis of the aorta <img src='img/arrows/WS.png'/> with contrast projecting beyond the expected margin of the aortic wall <img src='img/arrows/WO.png'/> and adjacent thickening of the aortic wall <img src='img/arrows/BO.png'/>. The descending aorta is typically involved.*
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*Oblique catheter angiography shows a small contrast outpouching <img src='img/arrows/WO.png'/> on the wall of the descending thoracic aorta, representing an aortic ulceration. The aorta seems only mildly diseased on the aortogram.*
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*DSA in the same patient shows the outpouchings in the abdominal aorta <img src='img/arrows/BO.png'/>. There is mild common iliac artery atherosclerotic disease and more extensive disease involving the infrarenal aorta.*
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*Oblique CECT shows a large ulceration <img src='img/arrows/WO.png'/> in the transverse aortic arch. Additionally, the aorta has mild diffuse disease with scattered atherosclerotic calcifications <img src='img/arrows/BO.png'/>.*
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*Axial CECT shows contrast extending through a defect <img src='img/arrows/WO.png'/> in the mural thrombus <img src='img/arrows/BS.png'/> that lines the aortic lumen. There is calcification in the aortic wall <img src='img/arrows/WC.png'/> and an area of soft tissue density outside the aorta <img src='img/arrows/WS.png'/>, which could represent bleeding.*
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*DSA shows a focal outpouching of contrast <img src='img/arrows/WO.png'/> in the descending thoracic aorta. This contrast collection persists after it has almost completely cleared from the remainder of the aorta. This abnormality could be treated with endovascular stent grafting.*
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*Coronal MR angiogram shows 2 areas of focal outpouching <img src='img/arrows/WO.png'/> in the distal abdominal aorta. Although penetrating ulcers are uncommon in the abdominal aorta, these areas are suspicious. There is also common iliac artery atherosclerotic disease <img src='img/arrows/WS.png'/>.*
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*Axial CECT shows a diseased and ectatic aortic arch with moderate atherosclerotic calcification <img src='img/arrows/WS.png'/>. There is a focal outpouching of contrast <img src='img/arrows/WO.png'/> projecting from the lateral aortic wall, which represents a PAU.*
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*Axial chest CTA in a patient with PAU along the descending thoracic aorta shows a contrast collection <img src='img/arrows/BS.png'/> extending beyond the expected aortic margin. Note surrounding soft tissue <img src='img/arrows/BO.png'/>, consistent with focal IMH.*
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*Sagittal CTA in the same patient shows a well-defined PAU <img src='img/arrows/BC.png'/>. Note adjacent atherosclerotic plaques <img src='img/arrows/BS.png'/>. In contrast to mycotic pseudoaneurysm or traumatic aortic injury, PAU is invariably associated with atherosclerosis.*
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*Axial CTA in a patient with PAU and aneurysm of the descending thoracic aorta with aortic dissection shows an ulceration <img src='img/arrows/WS.png'/> with conspicuous, thick, intimomedial, flap-like margins <img src='img/arrows/BC.png'/> in a location not classic for aortic dissection. These are helpful features to differentiate aortic dissection arising from PAU from classic aortic dissection.*
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*Axial chest CTA in a patient with ulcerated atherosclerotic plaque <img src='img/arrows/WS.png'/> shows that, as opposed to PAU, the ulcerated plaque does not extend beyond the expected aortic wall margin.*
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