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(Circulation. 2001;103:e18.)
© 2001 American Heart Association, Inc.

Images in Cardiovascular Medicine

Contrast-Enhanced Magnetic Resonance Angiogram of Penetrating Aortic Ulcer

R. H. Mohiaddin, MD, PhD; J. McCrohon, MD; J. M. Francis, DCR; M. Barbir, MD; D. J. Pennell, MD

From Royal Brompton and Harefield NHS Trust, London, UK.

Correspondence to Raad H. Mohiaddin, MD, PhD, MRCP, FRCR, FESC, Magnetic Resonance Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. E-mail r.mohiaddin{at}rbh.nthames.nhs.uk

A 56-year-old man presented with sudden severe chest and back pain. His chest x-ray showed a slight prominence on the upper descending thoracic aorta. Aortic dissection (type B) was visible on transesophageal echocardiography and CT. Coronary angiography showed normal coronary arteries. MRI and contrast-enhanced magnetic resonance angiography (CE-MRA) confirmed the diagnosis of type B aortic dissection involving the distal aortic arch and descending aorta (Figure). In addition, the CE-MRA depicted an intramural hematoma in the outer curvature wall of the distal aortic arch and the proximal descending thoracic aorta, with a button-shaped focal signal enhancement that was consistent with a penetrating aortic ulcer. The arterial phase MRA showed the aortic ulcer and the true and false aortic lumina, with less contrast in the partially thrombosed false lumen and the intramural hematoma when compared with the late phase MRA. The patient was treated conservatively and is currently well and asymptomatic. To our knowledge, this is the first report of a penetrating aortic ulcer demonstrated by CE-MRA.

View larger version (49K): [in this window] [in a new window]   Figure 1. CE-MRA (a, arterial phase; b, late phase) depicted intramural hematoma (IMH) in outer curvature wall of distal aortic arch and in proximal descending thoracic aorta, with button-shape focal signal enhancement (arrows) consistent with penetrating aortic ulcer. Arterial phase MRA showed aortic ulcer and true (t) and false (f) aortic lumina, with less contrast in partially thrombosed false lumen and intramural hematoma when compared with late phase MRA.

A penetrating atherosclerotic ulcer of the descending thoracic aorta, which is a potentially fatal aortic catastrophe, is characterized on angiography by focal enhancement beyond the confines of the aortic lumen but communicating with the lumen.^{1 2} Because of the rare occurrence of aortic ulcers, the prognosis, outcome, and management of such patients are still not clear.^{1 3} Accurate diagnosis of penetrating aortic ulcers is sometimes difficult. CT may demonstrate the surrounding hematoma and displaced calcifications. MRI, including CE-MRA, is a versatile method for assessing aortic disease and seems well suited for the characterization of penetrating aortic ulceration. This is important because surgery to repair a penetrating ulcer requires more extensive aortic resection than does the repair of a dissection, and it involves placing a longer aortoaortic interposition graft in an atherosclerotic aorta that is often friable.²

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

References

1. Hussain S, Glover JL, Bree RL, et al. Penetrating atherosclerotic ulcers of the thoracic aorta. J Vasc Surg. 1989;9:710–717.[Medline] [Order article via Infotrieve]

2. Kazeronni EA, Bree RL, Williams DM. Penetrating atherosclerotic ulcers of the descending thoracic aorta: evaluation with CT and distinction from aortic dissection. Radiology. 1992;183:759–765.[Abstract/Free Full Text]

3. Cooke JP, Kazmier FJ, Orszulak TA. Penetrating aortic ulcer: pathologic manifestations, diagnosis and management. Mayo Clinic Proc. 1988;63:718–725.[Medline] [Order article via Infotrieve]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mohiaddin, R. H. Articles by Pennell, D. J. Search for Related Content PubMed PubMed Citation Articles by Mohiaddin, R. H. Articles by Pennell, D. J. Related Collections Cardiovascular imaging agents/Techniques CT and MRI CV surgery: aortic and vascular disease