Penetrating atherosclerotic ulcer

Purpose of review Penetrating aortic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media. With the advances in imaging techniques, the differential diagnosis between PAU and other aortic ulcers remains a challenge. This review aims to summarize the latest insight into PAU, based on clinical context and the newest imaging characteristics, to aid treatment decision-making. Recent findings Most PAUs are asymptomatic and do not require urgent invasive treatment. Nevertheless, when PAU leads to an acute aortic syndrome, emergency invasive therapy is recommended. A differential diagnosis with other lesions, such as ulcerated plaques or intimal disruptions within the context of an aortic intramural hematoma, is required as the risk of complications and management differ. Imaging technique plays a pivotal role in the correct diagnosis of aortic ulcers. Summary The differential diagnosis of PAU with other aortic ulcers based on clinical and imaging technique information is mandatory as it may imply different prognosis and management. This diagnosis is particularly important when PAU is the cause of acute aortic syndromes as urgent invasive treatment should be recommended.