What is the next step in management for a 62-year-old male with an incidental penetrating ulcer of the right common iliac artery and adjacent inflammation on CT, without lower abdominal pain?

Management of Incidental Penetrating Ulcer of the Right Common Iliac Artery

The next step in management for a 62-year-old male with an incidental penetrating ulcer of the right common iliac artery with adjacent inflammation/stranding on CT without lower abdominal pain should be urgent vascular surgery consultation followed by CTA pelvis with runoff to fully evaluate the extent of disease. 1, 2

Initial Evaluation

• Penetrating atherosclerotic ulcers (PAUs) of the iliac artery are critical findings that can lead to "aortic catastrophe" including aneurysm formation, false aneurysm development, and potential rupture 3
• Despite the absence of symptoms, the presence of inflammation/stranding adjacent to the penetrating ulcer indicates active disease that requires prompt evaluation 4, 2
• CTA pelvis with runoff is rated as "usually appropriate" (8/9) by the American College of Radiology for evaluation of iliac artery disease and should be performed to:
  • Assess the extent of the penetrating ulcer
  • Evaluate for associated aneurysmal changes
  • Identify any other vascular lesions 1

Management Algorithm

1. Immediate Consultation:

   • Urgent vascular surgery consultation is required due to the high-risk nature of penetrating ulcers, even when incidentally discovered 2

2. Advanced Imaging:

   • CTA pelvis with runoff to fully characterize the lesion and assess for:
     • Extent of penetration through arterial wall
     • Presence of associated aneurysm
     • Degree of surrounding inflammation
     • Other vascular lesions 1

3. Risk Stratification:

   • Based on imaging findings, the lesion should be classified according to:
     • Depth of penetration
     • Presence of associated aneurysm
     • Extent of inflammation
     • Anatomic location 1, 5

4. Treatment Decision:

   • For high-risk features (extensive inflammation, deep penetration, or aneurysmal changes):
     • Endovascular repair with stent placement is recommended 5
   • For stable lesions with minimal inflammation:
     • Close surveillance with repeat imaging in 1-3 months 1

Treatment Considerations

• Even asymptomatic penetrating ulcers with inflammation require intervention due to the high risk of progression to aneurysm formation and potential rupture 3, 2
• Endovascular approaches are preferred for common iliac artery lesions, with primary stenting being highly effective for focal lesions 1, 6
• Antiplatelet therapy should be initiated as part of management, with ASA 75-325mg daily recommended for patients with arterial disease 1, 7

Important Caveats

• Do not be falsely reassured by the absence of symptoms, as penetrating ulcers can rapidly progress to life-threatening complications even when asymptomatic 3, 2
• Inflammation/stranding adjacent to a penetrating ulcer on CT is a concerning finding that suggests active disease process requiring prompt evaluation 4
• Isolated iliac artery aneurysms are rare (2% of patients) but have a high propensity to increase in size and rupture if left untreated 2
• Septic endarteritis is a potential complication that can lead to fatal iliac wall rupture, particularly if intervention is delayed 4