The silent threat: a case report of a penetrating aortic ulcer

Abstract

BACKGROUND: Penetrating aortic ulcer (PAU) is a rare condition characterized by an aortic wall irregularity caused by the ulceration of an atheromatous plaque extending through the intima into the aortic media. PAU accounts for only 2–7% of acute aortic syndromes. Often, this disease remains asymptomatic while still having the potential to cause serious complications, making careful diagnosis essential. CASE PRESENTATION: An 84-year-old female with a long-standing history of hypertension and peripheral artery disease was admitted to the hospital due to headache, dizziness, and tinnitus. Physical examination revealed blood pressure of 220/74 mm Hg. Laboratory tests revealed normocytic anemia (11.4 g/dL) and elevated creatinine levels [1.26 mg/dL, estimated glomerular filtration rate (eGFR) 43.1 mL/min]. Carotid artery ultrasound showed significant stenosis (70–90%) of the left internal carotid artery. Given the patient’s comorbidities, further evaluation of the renal arteries was conducted. Doppler ultrasound revealed left renal artery stenosis and suspicion of PAU. Subsequent computed tomography angiography (angio-CT) confirmed the diagnosis, revealing an aneurysmal dilation up to 27 mm, beginning 58 mm above the aortic bifurcation. Contrast enhancement extended toward the aortic protrusion, suggesting an atherosclerotic plaque ulcer or a partially coagulated pseudoaneurysm. Antihypertensive and lipid-lowering therapy was administered, and the patient was referred to vascular specialists. CONCLUSIONS: In high-risk patients, assessing the possibility of aortic disease is essential. However, the infrequent location of PAU and its asymptomatic course requires vigilant diagnostics and poses a significant risk of complications. Strict blood pressure control remains crucial as hypertension is a strong predisposing factor.

Keywords

• hypertension
• peripheral artery disease
• penetrating aortic ulcer
• aortic disease
• acute aortic syndromes