Penetrating aortic ulcer manifesting as atypical chest pain

Journal of Cardiovascular Medicine, 2010

Penetrating ulcer of the aorta has been recognized as a distinct aortic disorder, defined by the ulceration of an atherosclerotic plaque. The lesion has the potential to evolve acutely into aortic rupture, but chronic pictures are possible. Late evolution into rupture, frank aortic dissection and progressive aortic enlargement have been documented. We discuss different modalities of presentation on the basis of recent clinical cases. As the optimal treatment, either surgical (open or endovascular) or medical, is based on a correct diagnosis, we highlight the importance of including aortic ulcers in the differential diagnosis of chest pain. Although endovascular treatment can be advisable in cases with favorable anatomic condition and in patients with multiple comorbidities, the open surgical option should be available given the heterogeneous location and clinical scenarios of these lesions.

Journal of Vascular Surgery, 1998

Background: Although classic type A and B aortic dissections have been well described, less is known about the natural history of penetrating atherosclerotic ulcers of the thoracic aorta. This study differentiates penetrating ulcer from aortic dissection, determines the clinical features and natural history of these ulcers, and establishes appropriate correlates regarding optimal treatment. Methods: A retrospective review of patient records and imaging studies was conducted with 198 patients with initial diagnoses of aortic dissection (86 type A, 112 type B) at our institution from 1985 to 1997. Results: Of the 198 patients, 15 (7.6%) were found to have a penetrating aortic ulcer on re-review of computed tomographic scans, magnetic resonance images, angiograms, echocardiograms, intraoperative findings, or pathology reports. Two ulcers (13.3%) were located in the ascending aorta; the other 13 (86.7%) were in the descending aorta.

International Journal of Angiology, 1995

Penetrating aortic ulcer," an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the aortic wall, is rarely considered in the differential diagnosis of patients with sudden onset of severe chest or back pain. It has been suggested that it is a pathologic process that involves elderly hypertensive patients with severe atherosclerosis and rarely has been observed in the ascending aorta. To determine the characteristics of this process, 11 clinical, 2 hemodynamic, 3 angiographic, and 4 surgical variables were compared between 10 consecutive patients with penetrating aortic ulcers and 20 matched patients with classic acute aortic dissection. Clinical and hemodynamic variables were similar in the two compared groups. In the group of patients with penetrating ulcer, mean age was 58-6 years, previous hypertension was observed in six patients and the penetrating ulcer was located in the ascending aorta in six cases. Compared with patients with aortic dissection, more angiographic projections were necessary to obtain the diagnosis in the group of patients with penetrating ulcer (2.4 +-0.8 vs 1.7-+ 0.6; p < 0.05). In addition, the presence of angiographic aortic valve regurgitation was only observed in the group of patients with acute dissection (60% vs 0%; p < 0.01). Severe atherosclerosis was not present angiographically in any patient with penetrating ulcer. In conclusion, penetrating aortic ulcer can also affect middle-age patients without severe atherosclerosis and is frequently observed in the ascending aorta. Its form of presentation and clinical characteristics are similar to classic aortic dissection. The lack of confirmatory evidence of dissection with suggestive clinical history should raise the possibility of penetrating aortic ulcer.

În urm\torul articol prezent\m dou\ cazuri de ulcer aortic arterosclerotic care au beneficiat de atitudini diferite de tratament. Cu toate c\ este o patologie rar\, este din ce în ce mai frecvent diagnosticat\, o dat\ cu dezvoltarea ecografiei transesofagiene [i a computer-tomografului, adesea în situa]ii de urgen]\. Sunt discutate indica]iile operatorii [i este prezentat\ o trecere în revist\ a datelor din literatur\. Cuvinte cheie: ulcer aortic, hematom intramural aortic, disec]ie

Heart, Lung and Circulation, 2012

We are reporting a case of 66 year-old man who presented to a regional hospital with sudden onset of inter-scapular pain, radiating to anterior chest. Initial assessment was unremarkable except for high blood pressure and computed tomography (CT) of chest showing an intramural haematoma in the thoracic descending aorta. He was transferred to our institution for the medical management of his blood pressure and intramural haematoma of the aorta. A transoesophageal echocardiography confirmed the diagnosis but in addition demonstrated a penetrating atherosclerotic ulcer (PAU). Subsequently CT aortogram revealed a slow leak from the PAU. Endovascular repair with stent-grafting was urgently performed. He improved clinically and remained well on discharge. This case demonstrated that PAU, although rare and often under-recognised, is potentially life-threatening and should be considered in the evaluation of chest pain. Multi-modality imaging techniques can aid the diagnosis and guide appropriate and timely management.

Journal of Vascular Surgery, 1989

Penetrating ulcer of the thoracic aorta is defined as an atherosclerotic lesion of the descending thoracic aorta with ulceration that penetrates the internal elastic lamina, allowing hematoma formation in the media. There is controversy whether this lesion differs from classic acute type III aortic dissection, based on its location, radiographic findings, natural history, and recommended therapeutic approach. Of 47 patients with a diagnosis of aortic dissection seen at our hospital during a 2-year period, five patients had clinical and radiographic findings of penetrating ulcer. Each of the five patients had characteristic computerized tomographic (CT) findings and two patients had angiographic confirmation. In all patients CT showed subintimal hemorrhage, aortic wall enhancement, absence of a double lumen, and contrast extravasation through the ulceration. In both patients who underwent angiography, ulceration, subintimal hematoma, and absence of a false lumen were demonstrated. The clinical presentation in four patients simulated acute aortic dissection or expanding thoracic aneurysm. The other patient, who was normotensive, did not have symptoms referable to the thoracic aorta but was studied because of an abnormal chest x-ray film. None of these five patients required surgical intervention. All five patients were alive and free of symptoms at 6 months, 8 months, 14 months (two patients), and 30 months after the original diagnosis. Follow-up CT scans in four patients showed resolution of subintimal hematoma and some dilatation of the lumen but no progression to rupture or aneurysm. Other authors stress the importance of differentiating symptomatic penetrating atherosclerotic ulcers from acute type III aortic dissection because of the higher incidence of rupture of penetrating ulcers and therefore recommend early surgical intervention. Our series suggests that rupture of symptomatic atherosclerotic ulcers of the thoracic aorta may be less common than previously thought and that nonoperative management is appropriate initially, followed by serial CT evaluation and clinical foUow-up.

Journal of Community Hospital Internal Medicine Perspectives, 2016

Chest pain is a very common symptom and can be of cardiac or non-cardiac origin. It accounts for approximately 5.5 million annual emergency room visits in the United States, according to 2011 CDC data. Penetrating atherosclerotic aortic ulcer (PAU), an uncommon condition, is also a potential cause of chest pain. We here report the case of a 65-year-old woman who presented with atypical chest and back pain. The pain persisted for 4 weeks necessitating two emergency room visits. Initial tests were non-significant including cardiac troponins, an electrocardiogram (EKG), and a chest X-ray on her first visit. Upon her second visit, she underwent a computed tomography angiogram of chest with contrast which revealed a PAU with an intramural hematoma in descending aorta. The PAU was finally diagnosed with an exclusion of other chest pain causes. She was treated non-surgically with a blood pressure control strategy and pain management. After a 2-month period of smoking cessation and following the achievement of a controlled blood pressure, she felt well without chest pain.

বাংলাদেশ এশিয়াটিক সোসাইটি পত্রিকা, ডিসেম্বর ২০১৯

সারসংক্ষেপ মরিস ব্লাশোঁর ‘লিটারেচার এন্ড দ্য রাইট টু ডেথ’ প্রবন্ধটি পশ্চিমা সাহিত্যতত্ত¡ ও সাহিত্য-সমালোচনার ধারায় বিশেষভাবে গুরুত্বপূর্ণ এজন্য যে, লেখক-টেক্সট-পাঠক ত্রয়ীর যে নতুন সম্পর্ক ও আপেক্ষিক গুরুত্বের নিরিখে বিশ শতকের দ্বিতীয়ার্ধের চর্চা বিকশিত হয়েছিল, প্রবন্ধটিকে বলা যায় তার সূচনাবিন্দু। সাহিত্যকে দেখার এবং পড়ার একেবারেই নতুন এক তরিকা এ প্রবন্ধের বিস্তৃত পরিসরে বেশ জটিল অননুকরণীয় ভাষায় ব্লাশোঁ প্রস্তাব করেছিলেন। তাতে সাহিত্যের ভাষা ব্যাখ্যার প্রভাবশালী ধারার সূত্রপাত হয়। ব্লাশোঁ দুই দফা নেগেশন বা অস্বীকৃতির ধারণা প্রতিষ্ঠা করেন, যার মধ্য দিয়ে লেখকের সাথে টেক্সটের বিচ্ছেদ নিশ্চিত হয় এবং স্বাধীন সত্তা হিসাবে টেক্সট ও পাঠক আবির্ভূত হয়। পশ্চিমা দর্শনের গুরুত্বপূর্ণ বর্গ ‘মৃত্যু’ অবলম্বন করে ব্লাশোঁ সাহিত্যের বিশিষ্টতা, কার্যকরতা ও শ্রেষ্ঠত্বের ধারণা প্রতিষ্ঠা করেন। বর্তমান প্রবন্ধে সারাংশ ও সারমর্মের ভিত্তিতে এই ধারণাগুলো উপস্থাপিত হয়েছে। ধারণাগুলো পঠিত হয়েছে পশ্চিমা পাঠ-শাস্ত্রের ধারাপ্রবাহের মধ্যে।

LOURDES ROBLES MURRIETA TOPOGRAFIA ING. ARTURO MORALES QUINTERO 13/05/15 CINTA METRICA

Saluran pencernaan berawal dari mulut, tempat makanan pada awalnya dikunyah atau dimastikasi dan dicampur dengan sekresi saliva. Mastikasi adalah proses pemecahan makanan secara mekanik yang sistematik di mulut. Jumlah mastikasi yang diperlukan untuk menelan makanan bergantung pada jenis makanan yang diingesti. Mastikasi melibatkan aktivitas terkoordinasi dari gigi, otot-otot, rahang, sendi, temporomandibula, lidah, serta struktur-struktur lain seperti bibir, palatum, dan kelenjar saliva.