Abdominal Aortic Aneurysm with Retrograde Iliac Dissection and Multifocal Penetrating Ulcers: A High-risk Vascular Entity

Penetrating atherosclerotic ulcer (PAU) is a distinct subtype of acute aortic syndrome, accounting for 2%–8% of cases. It arises from plaque rupture with focal intimal disruption and may progress to intramural hematoma, saccular aneurysm, pseudoaneurysm, dissection, or rupture. Although most PAUs occur in the descending thoracic aorta, abdominal involvement is uncommon and have associated aneurysms, reflecting shared pathophysiology and heightened rupture risk. We report a case of multiple abdominal PAUs associated with an infrarenal abdominal aortic aneurysm complicated by retrograde dissection and bilateral iliac artery disease. Endovascular aneurysm repair (EVAR) successfully excluded all aneurysmal and dissecting segments, preventing rupture while avoiding the morbidity of open repair.