Aortic ulcer

Ulcers occur frequently in our lives. The most typical example is oral ulcers, which are characterized by intense pain. They are not very harmful, but have a significant impact. Ulcers, also known as aortic ulcers, can also occur in the aorta, a very heavy blood vessel in the human body. Ulcers and the aorta seem unrelated, so why are they connected? Let’s take a closer look below.

The full name of aortic ulcer is "penetrating atherosclerotic ulcer of the aorta". PAU is usually caused by atherosclerosis. Atherosclerotic lesions all begin to develop from the intima of the arteries, with lipid accumulation, fibrous tissue hyperplasia, and calcium deposition occurring successively to form atherosclerotic plaques. As plaques form, degenerative changes in the arterial media layer also occur. The inner membrane of the atherosclerotic plaque ruptures, eventually forming an atherosclerotic ulcer.

PAU was first described by Shennan in 1934 in the context of aortic dissecting aneurysms. However, it was not until 1986 that Stanson first clarified the pathological characteristics of PAU and defined it as an independent aortic pathological change. In 2003, Macura elaborated on the differences between penetrating aortic ulcer (PAU), aortic dissection (AD), and aortic intramural hematoma (IMH): typical AD has primary intimal rupture (entrance) and re-rupture (exit), there is continuous blood perfusion between the true and false aortic cavities, and the lesions are mainly located between the intima and media of the aorta; IMH is the rupture of the nutrient vessels of the aortic wall, forming a hematoma between the media and adventitia of the artery, without intimal rupture and no blood flow communication with the aortic cavity; PAU is an ulcerative lesion in the aortic intima. AD and IMH extend along the longitudinal axis of the aorta to the proximal and distal aortic walls. The lesions are extensive and may affect the entire aorta and its branches; PAU progresses outward along the transverse axis of the aorta, invading the media and even penetrating the adventitia to form a pseudoaneurysm.

2 Clinical features of aortic ulcer

After PAU penetrates the internal elastic membrane, it manifests as acute onset of severe tearing pain in the chest and back, which is similar to other acute aortic diseases (including typical AD and IMH, etc.), so it is collectively called acute aortic syndrome.

Since conventional examination methods such as chest X-ray and transthoracic ultrasound have low diagnostic sensitivity for PAU, the detection rate of PAU is not high. PAU may also progress to IMH, typical AD and pseudoaneurysm, which may be different stages of the same disease, so the incidence of PAU is not particularly clear. According to current literature estimates, approximately 2.3% to 11% of acute aortic syndrome (AAS) are caused solely by PAU.

The clinical manifestation of PAU is pain, just like that of peptic ulcer, but the nature, location, degree and accompanying symptoms of the pain are very different. PAU may have no obvious symptoms in the early stages; after penetrating the internal elastic membrane, there will be an acute onset of severe tearing pain in the chest and back; some patients may also experience chronic back pain that is not related to musculoskeletal disease. Other clinical characteristics of PAU are: the average age of patients is high, most of them are over 70 years old; often accompanied by extensive aortic atherosclerosis; lesions are prone to occur in the descending aortic arch and abdominal aorta; often accompanied by hypertension, hyperlipidemia, coronary heart disease and other concomitant diseases; often have a long history of heavy smoking, etc.