Penetrating Atherosclerotic Ulcers of the Abdominal Aorta: A Case Report and Review of the Literature

Penetrating atherosclerotic ulcers (PAUs) of the aorta are defined as atherosclerotic lesions with aortic intima and media ulceration, which may lead to a complete rupture of the adventitial wall. The present article aimed to report an unusual case of a surgically treated patient with abdominal aorta PAU with an illustration of the key features and to review and analyze the existing literature data. PAUs typically develop in elderly and hypertensive patients and in patients with advanced atherosclerosis. Although originally described for the descending thoracic aorta, a similar clinicopathological entity also occurs in the abdominal aorta. Patients with symptoms of a PAU should be treated immediately if they are fit for surgery. Exceptive observation by imaging modalities is necessary in patients with asymptomatic small (<2 cm) PAU, with or without focal dissection.

Combination of Ascending Aortic Replacement and Less Invasive Quick Open Stenting for Distal Aortic Arch Aneurysm with a Penetrating Atherosclerotic Ulcer / 日本心臓血管外科学会雑誌

A 76-year-old man with hypertension had an enlarged distal aortic arch aneurysm with a maximum dimension of 55 mm. Coronary computed tomography angiogram showed none of stenosis in a coronary artery, but penetrating atherosclerotic ulcer at ascending aorta. We performed open surgical repair combination of ascending aortic replacement and less invasive quick open stenting (LIQS) to reduce operative risk, because of his advanced age. The operation was carried out without any complications (Operation time : 242 min, Cardiopulmonary bypass time : 154 min, Aortic cross clamp time : 71 min). The patient's postoperative course was unremarkable, and he was discharged 19 days after surgery. LIQS is effective to reduce operative risk for high-risk patients, and it can be easily combined with other procedures.

A Case of Ruptured Penetrating Atherosclerotic Ulcer of the Thoracic Descending Aorta That Previously Had Asymptomatic Focal Ulceration / 日本心臓血管外科学会雑誌

We encountered a case of ruptured penetrating atherosclerotic ulcer (PAU) that previously had focal ulceration. A 82-year-old man was followed on a diagnosis of distal arch true aneurysm with a diameter of 4.5cm on CT examination. He was admitted with sudden onset of back pain, but he had experienced no previous symptom. CT scan showed a ruptured penetrating atherosclerotic ulcer, therefore we performed emergency replacement of the thoracic descending aorta. The postoperative course was good. CT scan showed the thoracic descending aorta had focal ulceration with a width of 11mm and depth of 7mm at 6 months, however the width was 11mm and the depth was 11mm 1 month before rupture of the PAU. This suggested progression of the focal ulceration caused the PAU rupture.

A Case Report of Impending Ruptured Suprarenal Abdominal Aortic Aneurysm Associated with a Penetrating Atherosclerotic Ulcer / 日本心臓血管外科学会雑誌

A 71-year-old woman was admitted with sudden onset of abdominal pain. CT scan image and symptoms showed an impending ruptured suprarenal abdominal aortic aneurysm therefore we performed an emergency operation. The abdominal aorta was replaced with a trunk prosthetic graft with four branches for visceral and lumbar arteries. The post-operative course was uneventful. Pathological examination showed that the aorta had severe atherosclerotic changes. The fibrous tissues increased in the aneurysmal wall which was not consistent with the normal aorta. Intima and media of the aorta everted into the aneurysm. These findings suggested that aneurysm was caused by a penetrating atherosclerotic ulcer.

A Case Report of Double False Aneurysms Associated with a Penetrating Atherosclerotic Ulcer / 日本心臓血管外科学会雑誌

A 72-year-old man was admitted with an abnormal shadow on chest X-ray. Chest CT and aortography showed double saccular aneurysms at the aortic arch and the descending thoracic aorta. Three-dimensional CT was useful to detect the association between the arch aneurysm and neck vessels. Graft replacement, from the distal arch to the descending thoracic aorta, was performed by the lateral approach with hypothermic arrest and open proximal method. The aorta had severe atherosclerotic changes and the intima was absent at the orifices of the aneurysms. Pathological examination showed the aneurysmal wall to be composed of fibrous tissue without medial components. These macroscopic and pathological findings of aneurysms corresponded with double pseudo-aneurysms originating from the penetrating atherosclerotic ulcer.

A Case of Extended Intramural Hematoma of the Ascending Aorta Due to Penetrating Atherosclerotic Ulcer / 日本心臓血管外科学会雑誌

An 81-year-old woman with severe chest pain was admitted to our hospital. Computed tomography showed aortic dilation and a non-enhanced crescentic area in the ascending aortic wall, indicating a DeBakey type-II aortic dissection with thrombus. The ascending aorta was replaced with an impregnated knitted Dacron graft. Fresh clotted hematoma was found in the dissected ascending aortic wall, and the intimal surface was involved with a local atherosclerotic ulcer penetrating the media. Operative findings were compatible with intramural hematoma due to penetrating atherosclerotic ulcer described by Stanson et al. In the literature most penetrating atherosclerotic ulcers are located in the descending aorta, thus this case is rare.