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A penetrating atherosclerotic ulcer (PAU) is an ulceration of an atherosclerotic plaque that breaches the internal elastic lamina and penetrates into the aortic media, potentially leading to intramural hematoma (IMH), pseudoaneurysm, or aortic rupture. PAU is part of the acute aortic syndrome (AAS) spectrum.

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Pathophysiology

• Develops in elderly patients with severe atherosclerosis
• Atherosclerotic plaque erosion progresses through the intima into the media
• Causes localized weakening, and may evolve into:
  • Aortic intramural hematoma (IMH)
  • Contained or free rupture
  • Saccular aneurysm

Epidemiology

• Typically occurs in older hypertensive males
• Strongly associated with diffuse atherosclerosis
• Accounts for ~5–10% of AAS cases

Common Sites

• Descending thoracic aorta (most common)
• May also affect:
  • Abdominal aorta
  • Ascending aorta (rare and more lethal)

Clinical Features

• Acute chest or back pain
• Hypertension
• May mimic:
  • Aortic dissection
  • Myocardial infarction
  • Pulmonary embolism
• May be asymptomatic, discovered incidentally