A 70 year old man with known systemic hypertension and hypercholesterolaemia presented for diagnostic evaluation of suspected aortic dissection. Previous routine ultrasonography raised suspicion of abdominal aortic dissection in the asymptomatic patient.

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Aortography showed severe atherosclerotic alterations of the aortic wall with a focal penetrating ulcer in the infrarenal aorta (A). Intravascular ultrasound (IVUS) examination revealed multiple penetrating aortic ulcers with intramural haematoma formation distal to the origins of the renal arteries extending to the aortic bifurcation (B, C, D). The largest ulcer measured 12 × 6 mm.

In order to prevent potential rupture, a custom made stent graft (Talent, Medtronic) 34 mm in diameter and 90 mm in length (covered) was implanted via the right femoral artery. Postimplantation angiography and IVUS showed complete coverage of the ulcerated lesions (E). The postoperative course of the patient was uneventful during a follow up period of six months.

Recently, penetrating atherosclerotic ulcer of the aorta (class IV dissection) has been identified as a potential precursor of aortic dissection. Intramural haematoma formation, pseudoaneurysm, and even transmural aortic rupture have been described as complications. Based on clinical presentation alone, patients may not be distinguished reliably from those with classic aortic dissection. So far, no generally accepted therapeutic regimen has been established. Endovascular stent graft placement may therefore provide a less invasive alternative to traditional surgery in the treatment of penetrating atherosclerotic ulcers.