Penetrating Aortic Ulceration With Pseudoaneurysm and Intramural Hematoma: Emergency Department Management and Point-of-Care Ultrasound Diagnosis

Abstract

Penetrating aortic ulcer (PAU) complicated by an intramural hematoma is a rare and potentially life-threatening emergency department (ED) presentation that is defined by progressive ulceration through the intima layer into the media layer of the aorta. Symptomatic PAUs can be clinically indistinguishable from other life-threatening pathologies such as aortic dissection, acute coronary syndrome (ACS), intrabdominal catastrophes as well as less lethal processes such as musculoskeletal back pain. Given the potential of PAUs to result in lethal aortic rupture and dissection, the emergency provider should maintain a high index of suspicion in patients with risk factors for aortic pathologies and utilize diagnostic modalities such as point-of-care ultrasound (POCUS) to expedite diagnosis.

Keywords: aortic dissection; aortic injury; aortic ulceration; emergency medicine; peripheral arterial disease.

Figure 1. Sonogram depicting an asymmetric outpouching of the aortic wall without an intimal flap

Figure 2. Computed tomography angiography (CTA) axial view, demonstrating aortic ulceration with pseudoaneurysm and intramural hematoma extending through the aortic wall

Figure 3. Coronal view CTA demonstrating aortic ulceration with pseudoaneurysm and intramural hematoma extending through the aortic wall