From the Guidelines
The diagnosis based on the computed tomography angiography (CTA) findings is a penetrating atherosclerotic ulcer (PAU) in the anterior wall of the upper descending aorta, with no evidence of acute aortic dissection or intramural hematoma, and possible partial obstruction or other renal pathology in the left kidney. The CTA findings of moderate atherosclerosis with a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, no lobar consolidation or pleural effusion, and dilated upper pole calices in the left kidney are consistent with a PAU, as described in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. The presence of a PAU is a significant finding, as it can increase the risk of aortic rupture or dissection, particularly if it progresses or is complicated by other factors such as hypertension or atherosclerotic disease 1. The finding of dilated upper pole calices in the left kidney may indicate partial obstruction or other renal pathology, and further evaluation with dedicated renal imaging such as ultrasound or CT urography is recommended to determine the cause of the calyceal dilation. The management of PAU typically involves medical therapy, including pain relief and blood pressure control, as well as careful surveillance with repetitive imaging to monitor for progression or complications 1. In this case, since the PAU is uncomplicated and small, conservative management with regular surveillance and medical treatment may be considered, as recommended in the 2024 ESC guidelines 1. However, it is essential to continue monitoring the patient's condition and adjust the management plan as needed to prevent potential complications and improve outcomes. The absence of visible clots in the larger pulmonary arteries is reassuring, but pulmonary embolism cannot be completely excluded due to suboptimal visualization of subsegmental vessels, and further evaluation may be necessary if clinical suspicion persists. Overall, the diagnosis and management of PAU require a comprehensive approach, taking into account the patient's individual risk factors, clinical presentation, and imaging findings, as well as the latest guidelines and recommendations from reputable sources 1.
From the Research
Diagnosis Based on Computed Tomography Angiography (CTA) Findings
The diagnosis based on the CTA findings of no visualized pulmonary embolus, moderate atherosclerosis with a shallow penetrating ulcer in the atheromatous plaque of the anterior wall of the upper descending aorta, no lobar consolidation or pleural effusion, and dilated upper pole calices in the left kidney can be considered as follows:
- The presence of a penetrating atherosclerotic ulcer (PAU) in the descending aorta is a significant finding, as PAUs can cause aortic dissection or rupture 2.
- The location of the PAU in the upper descending aorta is consistent with the typical location of PAUs, which are most commonly found in the descending thoracic aorta 3, 4.
- The absence of a visualized pulmonary embolus, lobar consolidation, or pleural effusion suggests that the patient does not have a pulmonary embolism or other pulmonary pathology 5.
- The finding of dilated upper pole calices in the left kidney may indicate a possible renal issue, such as hydronephrosis, but this is not directly related to the aortic findings.
Potential Complications and Management
The patient's condition may be at risk for potential complications, including:
- Aortic dissection or rupture, which can be fatal if not promptly treated 2, 6.
- Intramural hematoma or pseudoaneurysm formation, which can also lead to severe complications 3, 4.
- The patient's management may involve close follow-up imaging, such as CTA, to monitor the progression of the PAU and the development of any complications 3, 4.
- Medical therapy, such as high-dose statin therapy, may be initiated to reduce the risk of further atherosclerotic progression and complications 4.