Prognostication of Asymptomatic Penetrating Aortic Ulcers

Quick Takes

  • Incidentally found asymptomatic penetrating aortic ulcer (PAU) has a relatively benign clinical course with minimal growth (<1 mm/year) and low incidence of complications (development of symptoms, radiographic progression, need for intervention, or rupture).
  • Patients with asymptomatic PAU can be conservatively managed with risk factor modification and serial imaging.

Study Questions:

What is the natural history of asymptomatic penetrating aortic ulcer (PAU)?


This is a retrospective single-center analysis of patients identified with having PAU from a pool of all patients who had undergone a computed tomography angiography (CTA) scan of the neck, chest, abdomen, or pelvis from 2005–2020. Patients with symptomatic PAU or with PAU at a prior surgical anastomosis were excluded. Symptom status was obtained by reviewing the medical record. Each patient with PAU (if multiple, the largest was selected and if multiple of the same size, the most proximal was selected) was followed longitudinally radiographically. The PAUs were characterized by aortic location, total aortic diameter, ulcer width, and ulcer depth. Baseline patient characteristics were collected. Primary outcomes were change in ulcer size over time and a composite outcome of development of symptoms, radiographic progression (i.e., to saccular aneurysm, dissection, or intramural hematoma), intervention, and rupture of the PAU of interest or of any other PAU if more than one. Linear mixed-effects modeling and time-to-event analysis with death as a competing risk were performed.


Of 58,800 patients who underwent a CTA during the study period, 273 (0.46%) were identified as having an asymptomatic PAU, while 94 patients (0.16%) had a symptomatic PAU. Mean age of the cohort was 75.5 ± 9.8 years with two-thirds being male. The most common medical comorbidities were hypertension (80.2%), hyperlipidemia (68.1%), coronary artery disease (58.6%), atrial fibrillation (52.4%), and chronic obstructive pulmonary disease (34.1%). The majority of PAUs (147 patients, 53.9%) were located in the descending thoracic aorta, followed by the abdominal aorta (zones 6-9) in 113 patients (41.4%), and then aortic arch (zones 0-2) in 13 patients (4.8%). Associated aortic disease was present in 6.2% at the site of PAU and distant aortic disease was present in 27.5%; 23.4% of patients had at least one other PAU. Initial mean ulcer width was 13.6 mm (95% confidence interval [CI], 12.7-14.6 mm), initial mean ulcer depth was 8.5 mm (95% CI, 7.8-9.1 mm), and initial total aortic diameter was 31.4 mm (95% CI, 30.1-32.7).

A total of 191 patients had at least one follow-up CT scan, with a median of four CT scans per patient (interquartile range [IQR], 2-8) and median radiographic follow-up of 3.5 years (IQR, 1.20-6.63 years). Change in ulcer width over time was 0.23 mm/year (95% CI, 0.01-0.46), in ulcer depth 0.14 mm/year (95% CI, -0.02-0.31 mm/year), and change in aortic diameter 0.24 mm/year (95% CI, 0.13-0.36). Factors associated with a statistically significant increase in PAU size over time were hypertension, hyperlipidemia, diabetes, initial ulcer width >20 mm, completely thrombosed PAU, and associated saccular aneurysm. Median clinical follow-up was 3.1 years (IQR, 1.0-6.0 years). The 5- and 10-year cumulative incidence of the primary outcome were 3.6% (95% CI, 1.6-6.9%) and 6.5% (95% CI, 3.1-11.4%), respectively. The composite outcome occurred in 12 patients (4.4%).


In this large cohort of patients with asymptomatic PAU, the vast majority demonstrated a stable course with minimal growth and low incidence of complications from PAU.


While PAU associated with intramural hematoma, rupture, or symptoms is typically repaired, the management of asymptomatic PAU has been variable and less clear. So-called “high-risk features,” including ulcer depth ≥10 mm, ulcer width ≥13-20 mm, significant growth in ulcer depth or width, saccular aneurysm, and increasing pleural effusion have been identified in other single-institution studies. This analysis demonstrates that the incidence of incidentally discovered asymptomatic PAU is low in a cohort of patients that had reason to undergo CTA, and that over time, the clinical course was relatively stable. In a patient population with elevated comorbidities in whom open or endovascular repair is associated with increased mortality/morbidity compared to those with other indications, these results provide guidance and reassurance that risk factor modification and imaging surveillance is an acceptable management strategy.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Dyslipidemia, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Computed Tomography, Nuclear Imaging, Hypertension

Keywords: Anastomosis, Surgical, Aneurysm, Aorta, Abdominal, Aorta, Thoracic, Atrial Fibrillation, Cardiac Surgical Procedures, Coronary Angiography, Coronary Artery Disease, Diabetes Mellitus, Diagnostic Imaging, Dissection, Endovascular Procedures, Geriatrics, Hematoma, Hyperlipidemias, Hypertension, Pleural Effusion, Pulmonary Disease, Chronic Obstructive, Primary Prevention, Radiography, Risk Factors, Tomography, X-Ray Computed, Ulcer, Vascular Diseases

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