Management of Ulcerated Aortic Plaques

Diagnosis and Risk Stratification

The American Heart Association recommends Transesophageal Echocardiography (TEE) as the gold standard for thoracic aortic plaque visualization, providing information on plaque mobility, ulceration, and composition 1
Computed Tomography Angiography (CTA) is recommended for comprehensive assessment to characterize the lesion and detect ulcer crater and thickened aortic wall 2
Magnetic Resonance Imaging (MRI) is an alternative when CTA is contraindicated 1
Risk factors for embolic complications include plaque thickness ≥4 mm, presence of mobile thrombi, ulceration, inflammation, hypertension, and plaque hemorrhage 1

The American College of Cardiology recommends anticoagulation therapy with warfarin (INR 2.0-3.0) or antiplatelet therapy to prevent embolic complications in patients with ulcerated aortic plaques 1
Blood pressure control is essential to reduce shear forces 1
Statin therapy is recommended to stabilize plaques and reduce stroke risk 1
Evidence suggests warfarin may be more effective than antiplatelet therapy in reducing stroke risk in patients with complex aortic plaques 1
For ulcerated plaques with high embolic risk (≥4 mm thickness or mobile components), anticoagulation with warfarin (target INR 2.0-3.0) or antiplatelet therapy (aspirin or other antiplatelet agents) is recommended 1

Thoracic endovascular aortic repair (TEVAR) is preferred for descending thoracic aorta 2
Open surgical repair is recommended when endovascular repair is not feasible 2
Intervention options are reserved for specific scenarios, including symptomatic PAU, rapid growth, development of complications, and size thresholds (PAU width ≥13-20 mm, PAU depth ≥10 mm) 2

Regular imaging surveillance with CTA, MRI, or TEE is recommended for uncomplicated ulcerated plaques managed medically 2
More frequent monitoring is recommended for symptomatic lesions, which have a higher progression rate compared to asymptomatic lesions 2
Location of the ulcerated plaque matters, with those in the ascending aorta carrying higher risk and potentially warranting more aggressive management 2

Fluoroquinolone antibiotics should be avoided in patients with aortic ulcers due to increased risk of aortic complications 4