Case Report

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American Journal of Emergency Medicine

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Unusual presenting of acute aortic dissection due to penetrating atheromatous ulcer

Abstract

Penetrating atheromatous ulcer (PAU) is an atherosclerotic ulcer penetrating the internal elastic lamina of the aortic wall causing a hematoma within the media layer of aorta. They are commonly located in the descending aorta of the elderly and Hypertensive patients. They may rarely be complicated by aortic dissection. We report a relative young normotensive patient presenting with acute aortic dissection due to PAU located in the ascending aorta.

Penetrating atheromatous ulcer (PAU) is an atherosclerotic ulcer penetrating the internal elastic lamina of the aortic wall causing a hematoma within the media layer of aorta [1]. Penetrating athero- matous ulcer usually involves the descending thoracic aorta and rarely seen in ascending aorta. There is limited data in the literature about PAU causing aortic dissection. We report a relative young normotensive patient presenting with acute aortic dissection due to PAU located in the ascending aorta.

A 51-year-old man was admitted to emergency department with severe retrosternal chest pain radiating to interscapular area that had begun 2 days ago. The medical history of the patient was insignificant except that he had dyslipidemia for 3 years. He was a current smoker. His blood pressure was 110/50 mm Hg, and heart rate was 96 per minute. He had normal heart sounds with a diastolic murmur of 2/6 grade at the second left intercostal space. He did not have difference between blood Pressure measurements obtained from the right and the left arms. Electrocardiogram did not reveal any findings suggestive of acute ischemia, whereas serum high- sensitive troponin T level was slightly increased. Transthoracic echocardiography showed a dilated ascending aorta (54 mm in diameter) with a dissection flap prolapsing into the left ventricle through aortic valves and severe aortic insufficiency (Fig. 1 A and B). transesophageal echocardiography confirmed that the dissec- tion flap was extending from the level of sinus valsalva to aortic arch and prolapsing into the left ventricle disturbing aortic valve coaptation (Fig. 1C and D). Acute Aortic dissection diagnosis was further confirmed by contrast enhanced chest computed tomo- graphic examination. The patient was immediately referred to cardiovascular surgery. At surgery, ascending aorta was seen dilated. Hematoma was ending at the beginning of the innominate artery. Dissecting membrane flap involved right coronary sinus and right coronary artery orifice probably originating from PAU localized in the posterior wall of the ascending aorta (Fig. 2). Bentall operation was successfully performed. The patient was discharged from cardiovascular care unit at postoperative fourth day. He was asymptomatic at his first follow-up visit.

acute aortic syndrome is characterized by the acute presentation of patients with one of several life-threatening thoracic aorta pathologies including aortic dissection, intramural hematoma, and PAU [2]. Penetrating atheromatous ulcer may be complicated by aneurysm formation, by breaking through into the adventitia to form a pseudoaneurysm, by rupturing completely (transmural rupture) into the mediastinum or the right and left hemithorax, and even by precipitating to an aortic dissection [3].

Penetrating atheromatous ulcer of the aorta was first described by Stanson et al [4] in 1986 as a distinct clinical and pathologic entity. They are commonly localized in the descending aorta and in elderly and hypertensive patients [5]. Vilacosta and Roman [2] reported that, among 194 consecutive patients who underwent TEE, 12 patients had documented PAU. All patients were hypertensive, and their mean age was 65 years. Aortic ulcers were located in the descending thoracic aorta in 8 patients, in the aortic arch in 2 patients, and in the ascending aorta in the remaining 2 patients. The initial working diagnosis was acute aortic dissection in 9 of them. In their retrospective study, Coady et al [6] reported that, of the 198 patients presenting with aortic dissection, only 15 had PAU, and PAU was located in ascending aorta in only 2 of them. They also noted that PAU was most often seen in severe atherosclerosis.

We report here an unusual presenting of acute aortic dissection due to PAU. Our patient had PAU in the ascending aorta, which is a rare location for PAU. On the other hand, he was middle aged, and he did not have hypertension. Dissection flap was originated from the PAU; it limited itself at the beginning of innominate artery where hematoma ended. All these findings suggested that PAU was the initiating event for dissection.

Halil Atas, MD Erdal Durmus, MD Murat Sunbul, MD

Department of Cardiology, Marmara University Faculty of Medicine

Istanbul, Turkey E-mail address: [email protected]

Yasar Birkan, MD

Department of Cardiovascular Surgery, Marmara University

Faculty of Medicine, Istanbul, Turkey

Beste Ozben, MD

Department of Cardiology, Marmara University Faculty of Medicine

Istanbul, Turkey

http://dx.doi.org/10.1016/j.ajem.2014.01.019

0735-6757/(C) 2014

Fig. 1. A and B, transthoracic echocardiogram showing the dissection flap in the ascending aorta. C and D, Transesophageal echocardiogram showing the dissection flap in the ascending aorta.

Fig. 2. Intraoperative photograph of ascending aorta showing penetrating atheroma- tous ulcer.

References

1. Macura KJ, Corl FM, Fishman EK, Bluemke DA. Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atheroscle- rotic aortic ulcer. AJR Am J Roentgenol 2003;181:309-16.
2. Vilacosta I, Roman JA. Acute aortic syndrome. Heart 2001;85:365-8.
3. Baliga RR, Nienaber CA, Isselbacher EM, Eagle KA. Aortic dissection and related syndromes. New York: Springer, Science; 2007. p. 3-15.
4. Stanson AW, Kazmier FJ, Hollier LH, Edwards WD, Pairolero PC, Sheedy PF, et al. penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1986;1:15-23.
5. Siegel Y. Penetrating atherosclerotic aortic ulcer rupture causing a right hemothorax; a rare presentation of acute aortic syndrome. Am J Emerg Med 2013;31(4):755.e5-7.
6. Coady MA, Rizzo JA, Hammond GL, Pierce JG, Kopf GS, Elefteriades JA. Penetrating ulcer of the thoracic aorta: what is it? How do we recognize it? How do we manage it? J Vasc surg 1998;27:1006-16.