Acute Aortic Syndrome: Penetrating Ulcer in Left Common Iliac Artery with Intramural Hematoma

Definition and Classification of Acute Aortic Syndrome

The American College of Radiology and European Heart Journal define acute aortic syndrome (AAS) as a condition characterized by arterial wall damage with dynamic and overlapping pathophysiology, similar clinical presentation, and common diagnostic and therapeutic approaches 1, 2
The European Heart Journal classifies AAS into three main entities: classic aortic dissection (Class 1), intramural hematoma (Class 2), and penetrating aortic ulcer (Class 3/4) 2, 4

The American College of Radiology notes that a penetrating ulcer refers to an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina, allowing hematoma formation within the media of the arterial wall 1, 5
The European Heart Journal states that intramural hematomas are characterized by blood seeping into the media at low pressure, forming a thrombus that pushes the outer wall of the artery outward 2, 4
The prevalence of isolated intramural hematomas in patients with suspected AAS is reported to be between 21% and 30% 5

The European Heart Journal recommends computed tomography (CT) with contrast as the diagnostic technique of choice, with a sensitivity of 96% for detecting intramural hematoma 2, 5
CT imaging shows a penetrating ulcer as a mushroom-shaped protrusion of the arterial lumen with outwardly facing edges, and an intramural hematoma as a crescentic or circular thickening of the arterial wall with a maximum thickness of 7 mm or greater 5

The European Heart Journal suggests that management depends on location, extent, and associated complications, and that endovascular repair should be considered for penetrating ulcers with intramural hematoma in iliac arteries if there is persistent pain, hematoma expansion, signs of distal ischemia, or risk of rupture 2, 4, 5