Penetrating aortic ulcer, intramural hematoma, acute aortic syndrome: when to do what.

Acute aortic syndrome (AAS) is a modern term to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges. These conditions include aortic dissection, intramural hematoma (IMH), and penetrating aortic ulcer (PAU). Population-based studies suggest that the incidence of aortic dissection ranges from 2.6-3.5 cases per 100,000 person/year; hypertension and a variety of genetic disorders with altered connective tissue are the most prevalent risk conditions. One in eight patients diagnosed with acute aortic dissection has either an IMH or a PAU. Pain is the most commonly presenting symptom of acute aortic syndrome and should prompt immediate attention including diagnostic imaging modalities (such as multislice computed tomography, transesophageal ultrasound, or magnetic resonance imaging). IMH and PAU need a specific therapeutic approach, because without treatment they have a very poor evolution, are unpredictable and can be worse than acute aortic dissection. All patients must receive the best medical treatment available at admission. High-risk but asymptomatic patients with IMH and PAU can probably be followed-up without intervention. All symptomatic patients will need treatment. In many of these patients, a direct surgical approach is often prohibitive, due to age and multiple comorbidities. Endovascular treatment offers superior results and is becoming a recognized indication for patients. Irrespective of treatment modality, a close follow-up is mandatory in order to detect disease progression.