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Fig. 10. —Diagram shows events leading to penetrating aortic ulcer from formation of extensive aortic atheroma confined to intimal layer, through lesion progression to deep ulceration of plaque with penetration into media, to entrance of blood from aortic lumen into media and splitting of media with intramural hematoma. Hematoma formation may extend along media, resulting in long-segment intramural hematoma.