What are the next steps in managing a possible penetrating atherosclerotic ulcer (PAU) in an adult patient with a history of hypertension and other cardiovascular risk factors, as shown on a computed tomography (CT) scan?

Management of Penetrating Atherosclerotic Ulcer on CT Scan

Immediately initiate aggressive medical therapy with intravenous beta-blockers targeting heart rate ≤60 bpm and systolic blood pressure <120 mmHg, then determine anatomic location (Type A vs Type B) to guide definitive management strategy. 1

Immediate Medical Management (All Patients)

Medical therapy is mandatory for all patients with PAU regardless of location or severity. 1

Hemodynamic Control Protocol

Heart Rate Control (First Priority):

• Target heart rate ≤60 beats per minute using intravenous beta-blockers as first-line therapy 2
• If beta-blockers are contraindicated, use non-dihydropyridine calcium channel blockers as an alternative 2
• Critical pitfall: Never initiate vasodilators before achieving heart rate control, as this provokes reflex tachycardia that increases aortic wall stress 2, 3

Blood Pressure Control (Second Priority):

• Target systolic blood pressure <120 mmHg and diastolic <80 mmHg 2
• After achieving heart rate control, if systolic BP remains >120 mmHg, add intravenous ACE inhibitors and/or other vasodilators 2

Pain Management:

• Provide adequate analgesia as part of initial management 3

Diagnostic Confirmation and Risk Stratification

Imaging:

• Contrast-enhanced CT is the diagnostic technique of choice with 96% sensitivity for detecting associated intramural hematoma 2, 3
• Look for the classic "mushroom-shaped protrusion" with overhanging edges penetrating through the internal elastic lamina 2, 3

High-Risk Imaging Features Requiring Intervention:

• Maximum PAU width ≥13-20 mm 1
• Maximum PAU depth ≥10 mm 1
• Significant growth of PAU width or depth >5 mm/year 1
• PAU associated with saccular aneurysm 1
• PAU with increasing pleural effusion 1
• Presence of intramural hematoma (rupture risk 33-75%) 3

Management by Anatomic Location

Type A PAU (Ascending Aorta)

Surgery is recommended for all Type A PAU. 1, 2, 3

• Emergency surgical repair is indicated due to extremely high rupture risk (33-75% when complicated with intramural hematoma) 3
• Exception: In highly selected patients with increased operative risk AND uncomplicated Type A PAU without high-risk imaging features, a "wait-and-see" strategy may be considered 1, 3

Type B PAU (Descending Thoracic Aorta)

Initial medical therapy under careful surveillance is recommended for all Type B PAU. 1, 2, 3

Complicated Type B PAU:

• TEVAR is recommended for complicated Type B PAU 1, 2, 3
• Complications warranting TEVAR include: recurrent or persistent pain despite medical therapy, expansion of IMH on serial imaging, periaortic hematoma, or intimal disruption 3

Uncomplicated Type B PAU with High-Risk Features:

• TEVAR should be considered (Class IIa recommendation) 1, 3
• This includes PAU with any of the high-risk imaging features listed above 1

Uncomplicated Type B PAU without High-Risk Features:

• Conservative management with regular surveillance and medical treatment may be considered for isolated, asymptomatic, small PAUs 1

Surveillance Protocol

For Medically Managed Type B PAU:

• Imaging (CT or MRI) at 1 month after diagnosis 1, 3
• Then at 3,6, and 12 months 1, 3
• Annually thereafter if stable 1, 3
• After 2 years of imaging stability, larger intervals should be considered in low-risk patients 1

Important consideration: Symptomatic PAU disease is significantly more likely to require repair (36.2% vs 7.8%) and to progress radiographically (42.9% vs 16.7%) compared to asymptomatic disease. 4

Long-Term Medical Management

Blood Pressure Control:

• Continue strict blood pressure control (systolic <120 mmHg) indefinitely 2, 3

Lipid Management:

• LDL-C reduction by ≥50% from baseline with goal <55 mg/dL (<1.4 mmol/L) using moderate-to-high intensity statins 3

Antiplatelet Therapy:

• Low-dose aspirin 75-162 mg daily to reduce cardiovascular event risk 2, 3

Key Clinical Pitfalls

• Most common error: Initiating vasodilators before heart rate control, which increases aortic wall stress through reflex tachycardia 2, 3
• Underestimating risk: PAU typically affects older males (>65 years) with multiple comorbidities including hypertension, coronary artery disease, COPD, and renal insufficiency—these patients have high baseline cardiovascular risk 1, 3
• Missing progression: Symptom onset may indicate PAU expansion involving the tunica adventitia, requiring urgent imaging and therapeutic intervention to prevent rupture 1, 3
• Inadequate follow-up: Even asymptomatic PAUs can progress (16.7% radiographic progression rate), necessitating close surveillance 4