Penetrating Aortic Ulcer

The aorta is the largest artery in the body. It rises from the heart's left ventricle (the major chamber that pumps blood out of the heart) and is filled with oxygen-rich blood that travels throughout the body. The artery is made up of multiple membrane layers that form the artery wall. When membranes within the body begin to break down at a specific point, they can create holes in the membrane that prevent the organ associated with it from functioning normally. Ulcers can form in the aorta from plaque that wears away at the artery wall lining and penetrates the artery wall.

Previously, this condition was considered a form of aortic dissection because it is similar and often has similar symptoms. However, in recent years, penetrating aortic ulcers have been recognized as a separate condition because there is no intimal flap present. The intimal flap is the section of artery wall that is torn and partially detached from the artery during aortic dissection.

Symptoms

Symptoms of a penetrating aortic ulcer typically occur soon after the ulcer develops and can vary from one patient to the next. The most common symptoms are severe chest and back pain. Other symptoms may include:

  • Severe abdominal pain
  • Shortness of breath
  • Pain in the arms or legs
  • Weakness
  • Loss of consciousness
  • Rapid, weak pulse
  • Heavy sweating
  • Anxiety
  • Pale skin
  • Nausea


Causes and Risk Factors

Penetrating aortic ulcer is uncommon and is most frequently diagnosed in older patients. The condition typically occurs in an area of the aorta that has plaque buildup due to atherosclerosis. The buildup of plaque causes that area of the aorta to weaken. The risk of developing atherosclerosis, and consequently a penetrating aortic ulcer, is increased by:

Diagnosis

Diagnosis of a penetrating aortic ulcer generally begins with the physician taking a medical history and performing a physical examination. During the physical exam the physician will listen to the patient's heart, lungs and abdomen using a stethoscope to see if there is any abnormal rhythm in the heartbeat.

To see the worn area of the aorta, more sensitive diagnostic tests may be used. A transesophageal echocardiography is a type of echocardiography that uses an ultrasound probe inserted through the esophagus. Other imaging tests such as a magnetic resonance angiogram (MRA), CT scan or aortic angiogram may be used to view the aorta and the tear. Some of the diagnostic imaging tests require a special dye to be injected into the vein so that it shows up more clearly on the images.

Other laboratory tests, such as blood tests, are often performed to rule out other conditions such as a heart attack.

Treatments

Because penetrating aortic ulcers are a life-threatening condition, treatment is usually needed immediately. When the condition occurs in the area of the aorta that is descending into the abdomen, treatment usually focuses on using medication to address the ulcer. This includes IV-administered beta blockers and sodium nitroprusside to lower the resting heart rate and control blood pressure. Medications do not correct a penetrating aortic ulcer located in the section of the aorta coming out of the heart. However, they may be used to stabilize the patient before surgery when the ulcer is in that location. Endovascular repair is the mainstay of treatment in the descending thoracic aorta, while open surgery is typically performed for the ascending aorta.

When the condition occurs in the ascending portion of the aorta, or if the condition cannot be managed with medication, surgery may be needed. Surgery will focus on removing the damaged section of the aorta and placing a graft in place of the removed section in order to prevent blood from running into the aortic wall. The graft is generally a tube made of synthetic material that helps restore function to the damaged area.

The knowledgeable and highly trained staff at the Cedars-Sinai Heart Institute will work with each patient to determine the best treatment option.