Penetrating Atherosclerotic Ulcerative Disease of the Aorta: Do Emergency Physicians Need to Worry?

BackgroundIn recent years, different aortic pathologies have been grouped together and described in terms of a spectrum of disease referred to as Acute Aortic Syndrome (AAS). Overlapping of these conditions has traditionally introduced discrepancy to the understanding of the pathophysiology and definitive care. Penetrating atherosclerotic ulcer (PAU), an ulceration of an atherosclerotic plaque, has been increasingly recognized as the individual cause of the acute aortic pathology.ObjectiveThe natural evolution and complications of PAU are described, as well as the current diagnostic strategies, definitive management options, and initial care in the emergency department.DiscussionThe natural history of PAU is variable but is generally considered to be an AAS with a high incidence of complications. The clinical differentiation of symptomatic PAU from other causes of AAS is very challenging. Computed tomography imaging has provided additional accuracy with the use of the retrospective electrocardiographic gating technique. Despite traditional surgical therapies for aortic pathology, later studies have demonstrated the success of non-operative management, such as endoluminal grafting.ConclusionThe relative rarity of this disease, the difficulties in its detection, and the lack of precise guidelines about its management may result in diagnostic delays. Asymptomatic patients with well-controlled blood pressure are safely managed as outpatients in close consultation with vascular surgery.