Emergent Care / Stabilization:
Emergent care is similar to aortic dissection care. This includes prompt blood pressure (BP) control with a systolic blood pressure (SBP) goal of 100-120 and heart rate control to about 60 beats per minute (bpm). This is typically controlled with intravenous (IV) esmolol titrated to effect; nicardipine can be added if necessary for additional SBP control. Note: Control heart rate prior to BP as reflex tachycardia can increase shearing force, worsening the pathology.

Consultation of surgical specialists: If the ascending thoracic aorta is involved, consultation should be with a cardiothoracic surgeon. If the descending aorta is involved, consultation should often be with a vascular surgeon. However, many hospitals have protocols in place to determine a responsible consultant.

Diagnosis Overview:
Penetrating atherosclerotic ulcer (PAU) is, first and foremost, an atherosclerotic lesion in the aorta that falls under the classification of acute aortic syndrome (AAS). Development of aortic atherosclerotic lesions is similar in pathophysiology to other atherosclerotic processes. It is more common in older adult patients (ages 60-90 years) with chronic comorbidities such as hypertension, hyperlipidemia, diabetes, and tobacco use, with hypertension having the highest association with PAU.

Significant pathology arises when the ulcers penetrate the elastic lamina of the aorta. When this occurs, hematoma formation is common and can serve as a nidus for aneurysm, dissection, or rupture. The interval development between ulceration, hematoma formation, and subsequent complications is currently not well defined. However, over time, the disease progresses and often results in a need for surgical management.

The presentation will differ somewhat based on the location of the ulcer. Ascending and thoracic PAU will often present with chest and back pain. If the abdominal aorta is involved, it may present with vague central abdominal pain or low back pain. If it has progressed to dissection, aneurysm, or rupture, it will present with associated classic symptoms. Approximately 90% of PAUs will occur in the descending thoracic aorta and abdominal aorta. Involvement of the ascending aorta and aortic arch are relatively uncommon.