title: A penetrating atherosclerotic ulcer rupture in the ascending aorta with hemopericardium: a case report.
abstract: BACKGROUND
  Acute aortic syndrome, including classic aortic dissection, intramural aortic hematoma, and penetrating atherosclerotic ulcer (PAU), is a term used to describe a group of conditions with similar clinical symptoms, but with different pathophysiological mechanisms. PAU is a lesion that penetrates the internal elastic lamina through the media. It is usually located in the descending aorta and rarely observed in the ascending aorta.
  
  
  METHODS
  A 76-year-old man with a history of essential hypertension was brought to the emergency department (ED) because of a sudden-onset chest pain at rest. He had not been taking his medication as ordered. His vital signs in the ED were a blood pressure of 82/60 mmHg, heart rate of 158 beats per min, respiratory rate of 22 breaths per min, and a body temperature of 37.2 °C. An electrocardiogram did not show an ST segment elevation, and cardiac enzymes were within normal limits. No widening mediastinum was found on chest radiography, but a large pericardial effusion with an impending cardiac tamponade was revealed on echocardiography. The diagnosis of PAU rupture in the ascending aorta with hemopericardium was made with chest computed tomography. An emergent sternotomy and ascending aorta reconstruction were performed. A ruptured ulcerative plaque through the intima to the adventitia without flap dissection in the ascending aorta was confirmed. The patient was discharged 18 days after the operation.
  
  
  CONCLUSIONS
  Although PAU in the ascending aorta is uncommon, it is commonly lethal when it ruptures. With the current advances in endovascular techniques and devices, endovascular repair of PAU in the ascending aorta is currently recommended only for high-risk patients unsuitable for open repair. However, we anticipate that endovascular repair may become feasible in patients with PAU in the ascending aorta in the future.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, Republic of China.
authors.forename: Yuan-Hao
authors.initials: YH
authors.lastname: Liu
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.
authors.forename: Hung-Yen
authors.initials: HY
authors.lastname: Ke
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China. m860630@mail.ndmctsgh.edu.tw.|Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan, Republic of China. m860630@mail.ndmctsgh.edu.tw.
authors.forename: Yi-Chang
authors.initials: YC
authors.lastname: Lin
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.|Division of Cardiovascular Surgery, Department of Surgery, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan, Republic of China.
authors.forename: Chien-Sung
authors.initials: CS
authors.lastname: Tsai
mesh_terms: D000368:Aged; D001011:Aorta / Q000000981:diagnostic imaging* / Q000601:surgery; D001019:Aortic Rupture / Q000000981:diagnostic imaging* / Q000601:surgery; D002305:Cardiac Tamponade / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D004452:Echocardiography; D006801:Humans; D008297:Male; D010490:Pericardial Effusion / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D058226:Plaque, Atherosclerotic / Q000000981:diagnostic imaging* / Q000601:surgery; D014057:Tomography, X-Ray Computed; D014456:Ulcer / Q000000981:diagnostic imaging* / Q000601:surgery
keywords: Acute aortic syndrome; Ascending aorta; Case report; Endovascular repair; Penetrating atherosclerotic ulcer