Clinical and Imaging Features of Aortic Penetrating Atherosclerotic Ulcers: A Systematic Review and Meta-Analysis

<b>Background/Objectives</b>: Penetrating atherosclerotic ulcer (PAU) is a type of acute aortic syndrome (AAS) characterized by an ulcer that penetrates from the inner lining into the middle layer of the aorta, often leading to serious complications such as intramural hematoma (IMH), aortic dissection, aneurysm, and rupture. PAU incidence has risen significantly in recent years. Advancements in imaging technologies like CT and MRI have improved early detection, yet the true prevalence remains unclear due to the asymptomatic nature of many cases. Thoracic endovascular aortic repair (TEVAR) is becoming the preferred treatment, but questions remain regarding its effectiveness in different clinical settings. This systematic review and meta-analysis aim to consolidate findings on PAU's clinical presentation, imaging characteristics, and outcomes to improve diagnosis, risk assessment, and treatment strategies. <b>Methods</b>: PubMed, Scopus, Embase, and Web of Science (WOS) were systematically searched from 1994 until November 2023. Related data were collected and evaluated. We used a random-effect model to calculate a forest plot, a funnel plot, pooled prevalence, and publication bias by STATA 18. <b>Results</b>: Of 1179 studies, 56 met the inclusion criteria, and we analyzed 3023 PAU patients. The 30-day mortality rate was 4.4%, with a late mortality rate of 15.6%. According to our study, open surgery, pre-operation (pre-op) aortic rupture, post-operation (post-op) endoleak, distant year of publication, symptomatic patients, lesions in the ascending aorta, and greater diameter of the lesion were associated with mortality. TEVAR was the most common treatment (67.3%), the endoleak rate was 3.7%, and re-intervention occurred in 4.4% of cases. Significant heterogeneity and publication bias were noted across several outcomes. <b>Conclusions</b>: PAU primarily affects elderly males with cardiovascular comorbidities; interventions like TEVAR reduce short-term mortality; however, long-term outcomes remain challenging, which indicates further investigation is needed into early detection and treatment.