From the Guidelines
The patient requires emergency attention due to the presence of a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, which is a high-risk feature that necessitates prompt evaluation and potential intervention. According to the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1, patients with penetrating atherosclerotic ulcers (PAU) should receive medical therapy including pain relief and blood pressure control, and those with complicated type B PAU or high-risk imaging features should be considered for endovascular treatment (TEVAR). The patient's current findings, including the penetrating ulcer and dilated upper pole calices of the left kidney, suggest a complicated condition that requires careful surveillance and potential intervention.
Key considerations in this case include:
- The presence of a penetrating ulcer in the descending aorta, which is a high-risk feature that necessitates prompt evaluation and potential intervention 1
- The patient's history of abdominal aortic aneurysm (AAA), which increases the risk of aortic complications 1
- The finding of dilated upper pole calices in the left kidney, which may represent a chronic condition that should be evaluated but is not immediately life-threatening
- The need for careful surveillance and potential intervention, as recommended by the 2024 ESC guidelines for patients with PAU 1
Given the complexity of the patient's condition and the potential for acute complications, it is not recommended to manage this patient solely by a primary care physician (PCP) without emergency attention and potential consultation with a vascular specialist. The patient should be evaluated promptly by a vascular specialist to determine the best course of treatment, which may include endovascular intervention or surgical repair, as recommended by the 2024 ESC guidelines 1.
From the Research
Patient Condition and Required Attention
The patient has a history of abdominal aortic aneurysm (AAA) and current findings of moderate atherosclerosis, a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, and dilated upper pole calices of the left kidney.
- The presence of a penetrating ulcer in the atheromatous plaque is a concern, as it can lead to aortic rupture or dissection, which are life-threatening conditions requiring prompt diagnosis and treatment 2, 3.
- The patient's condition can be classified as an acute aortic syndrome, which includes aortic dissection, intramural hematoma, and penetrating aortic ulcer 4, 5.
- The management of the patient's condition depends on the clinical presentation, timing, and location within the aorta 4, 6.
Treatment Options
- Medical treatment with sequential imaging is recommended in patients with uncomplicated course, and endovascular repair is indicated in patients with rupture, persistent pain, end-organ ischemia, or rapid aortic enlargement 4.
- A trial of medical therapy is recommended for patients with penetrating aortic ulcers (PAUs) and intramural hematoma (IMH) originating beyond zone 0 of the aorta 6.
- Progression of disease on imaging studies, persistent uncontrolled pain, and certain high-risk features warrant surgery 6.
- High-risk features signaling risk of disease progression include PAU with IMH, PAU depth more than 10 mm, PAU diameter more than 20 mm, IMH thickness more than 10 mm, and maximum initial aortic diameter more than 40 mm 6.
Required Care
- Due to the complexity and potential risks associated with the patient's condition, it is unlikely that a primary care physician (PCP) alone can manage the patient's care.
- The patient likely requires emergency attention and care from a specialist, such as a vascular surgeon or cardiologist, who can provide prompt diagnosis and treatment 2, 5, 3.