Abdominal Aortic Aneurysm

Aortic Aneurysm and its
Complications
Figure 1. Anatomy of thoracic and proximal abdominal aorta.
Isselbacher E M Circulation 2005;111:816-828
Copyright American Heart Association
Most
AAA are true aneurysms.
DEFINITION
Midascending aorta
<4 cm
Descending thoracic
aorta <3 cm
An aortic diameter of
3 cm or more is used
to define an AAA.
Most involve the
aortic segment
below the renal
arteries.
Figure 2. Contrast-enhanced CT scan demonstrating a 7.58.3-cm ascending thoracic aortic

aneurysm.
CAUSES atherosclerosis(most common)
inflammatory abdominal aortic

aneurysm
chronicaortic dissection
vasculitis, e.g.Takayasu arteritis
connective tissue disorders :e.g.
Marfan syndrome
Ehlers-Danlos syndrome
syphilis
mycotic aneurysm
traumaticpseudoaneurysm
anastomotic pseudoaneurysm
Risk factors
Strong risk factors of
AAA
Concurrent coronary
Prevalence: 2%4% of
the population older than
50 years.
More men than women
are affected.
artery disease
Concurrent
peripheral vascular
disease
A family history of
AAA
Clinical presentation
Asymptomatic(30%)
Abdominalmass
Abdominalpain
Imaging Techniques
USG
operator dependent, bowel

gas obstructs
CT
[modality of choice]
Speed, Availability
MRI
Much longer acquisition time,

Less available
Imaging Tecniques
Ultrasonography
(limited role in the assessment of acute aortic abnormalities)
Bowel gas, body habitus, operator

dependent.
Unstable patients to transfer for CT.
US may help determine the size of the
aneurysm and help identify
hemoperitoneum.
However, the utility of US for identifying
an impending rupture or a contained
rupture of an aneurysm is limited
Usg- round anoechic space defined by thick

hyperechoic walls
CT is the modality of
choice
NECT
may help detect an aneurysm rupture by

depicting an AAA with surrounding retroperitoneal
hemorrhage.
CT
angiography has become routine for imaging

of a suspected rupture. (R/O appendicitis,
pancreatitis, or bowel obstruction )
CECT
provides additional information about the

size of the aneurysmal lumen, presence of active
extravasation, and relationship of the aneurysm
to the celiac, SMA, renal, and IMA.
COMPLICATIONS
Aneurysm rupture
Infected Aneurysms
Aortic Fistulas
Inflammatory Aneurysms
Findings Predictive of
Impending Rupture
1.
Increased Aneurysm Size
2.
Thrombus and Calcifications
3.
Hyperattenuating Crescent Sign
Increased Aneurysm Size:

A patient with a very large AAA (diameter of 7 cm)
who presents with symptoms of acute aortic

syndrome has a high likelihood of aneurysm rupture.
Furthermore, an enlargement rate of 10 mm or more
per year is also used as an indication for surgical

repair.
The most common finding predictive of rupture and,
thus, the most common indicator for elective

surgical management, is the maximum diameter of
the aneurysm.
Thrombus and
Calcification :
A thick circumferential thrombus is protective
against rupture.
Nonruptured aneurysms generally contain more

thrombus than do ruptured aneurysms,
The thrombus-to-lumen ratio decreases with
increasing aneurysm size.
A focal discontinuity in circumferential wall
calcifications is more commonly observed in

unstable or ruptured aneurysms.
This finding is most helpful when a previous
CT study is available and its comparison with
the current CT study shows that an area of
discontinuity in mural calcifications is new.
Discontinuity of aortic wall calcifications in an abdominal aortic

aneurysm
3. Hyperattenuating Crescent
Sign : NECT
A well-defined peripheral crescent of
increased attenuation within the

thrombus of a large abdominal aortic
aneurysm is a CT sign of acute or
impending rupture.
It is one of the earliest and most
specific imaging manifestations of the

rupture process.
NECT (a) and contrast-enhanced (b)

CT scans show a high-attenuation crescent in the mural thrombus of an aortic aneurysm, a sign of impending
rupture or contained leak.
Finding of Aneurysm
Rupture
1. Subtle periaortic stranding 2. Hemorrhage into posterior

pararenal and perirenal compartment 3. Extravasation of iv.
contrast
CT - an aneurysm of the abdominal aorta and a large

hyperdense retroperitoneal hematoma due to rupture .
Secondary signs of AAA

rupture
High-attenuating crescent sign in a patient with subtle evidence of

leak adjacent to the right psoas muscle (broad arrow)
Focal discontinuity of intimal calcification
Tangential calcium sign intimal calcification points away from

aneursym and hemorrhage (broad arrow)
Finding of Aneurysm
Rupture
Draped aorta sign :
an important imaging feature that may
be seen in a contained rupture of an

AAA.
the posterior wall of the aorta either is
not identifiable as distinct from
adjacent structures or when it closely
follows the contour of adjacent
vertebral bodies.
1. Draped aorta. 2. rupture
Another patient who presented with

backpain. There was no evidence of
aneurysm leakage, but we see a
draped aorta.
Infected
Aneurysms
Prone to rupture
(a rupture rate of 53%75% at surgical repair)
Uncommon (0.7%2.6% of aortic aneurysms)
Most often pseudoaneurysms.
Most commonly caused by endocarditis.
The direct spread of infection from adjacent

vertebral osteomyelitis and from renal and
psoas abscesses also has been documented.
Majority occur in the thoracic or suprarenal

abdominal aorta.
CT findings of infected
aneurysms
Saccular shape and Lobular contours.
Periaortic inflammation, abscess, and
mass.
1.
2.
Other findings include
Periaortic gas.
Adjacent vertebral body abnormalities
due to the spread of infection.
CT-scan shows an important infra-renal abdominal aortic

aneurysm with an impressive intra-luminar and extra-luminal
air crescent
Aortic Fistulas
Most
fistulas involve the duodenum,

most commonly its third and fourth
portions.
Symptoms include abdominal pain,
hematemesis,
and melena.
Primary
Secondary
aortoenteric fistulas
complication of
atherosclerotic aortic
aneurysms
aortoenteric fistulas
a complication of
aortic reconstructive
surgery
Aortic Fistulas
Primary aortoenteric fistulas
A diagnostic dilemma for the clinician,
especially in the absence of gastrointestinal

tract bleeding.
Upper gastrointestinal tract endoscopy may
help rule out other causes of bleeding but
rarely helps diagnose a fistula.
CT Findings
1.
2.
3.
AAA ; often with signs of rupture.

Intraluminal and periaortic extraluminal gas.
Contrast material extravasation from the aorta into
the involved portion of the bowel (if a patent fistula
is present)
Surgical exploration is usually necessary to confirm the diagnosis

and for treatment.
Aortic Fistulas
Secondary aortoenteric fistulas
Much more common.
Aortoenteric fistulas have been
reported to occur between 2 weeks and

8 years after surgery
how an aortoesophageal fistula and intraesophageal rupture of a saccu

ttenuation blood is seen within the mediastinum in a and within the esophagu
can shows a focal rupture of the descending TAA, consolidation in the adjacent le
ung,and endobronchial blood in the left lower lobe segmental bronchus
Inflammatory
Aneurysms
Inflammatory abdominal aortic

aneurysm (IAAA)is a variant ofAAA,
characterised by inflammatory
thickening of the aneurysm wall, perianeurysmal fibrosis and adherence to
surrounding structures.
3%10% of aortic aneurysms
Predominantly found in men.
Inflammatory
Aneurysms
Slow
aneurysmal leakage was

initially thought to be its cause.
Cause
is thought to be related to
periaortic retroperitoneal fibrosis
and various autoimmune diseases
(rheumatoid arthritis, systemic
lupus erythematosus, and giant cell
arteritis).
Inflammatory
Aneurysms
Inflammatory
Aneurysm
Artherosclerotic
Aneurysm
Symptomatic
Increased risk of rupture
irrespective of their size
Asymptomatic
Increased risk of rupture
respective of their size
Symtoms & Signs : fever, weight loss, and

an elevated erythrocyte sedimentation
rate.
Inflammatory
Aneurysms
CT imaging features include
Inflammatory or fibrotic changes
in the periaortic regions of the

retroperitoneum.
CT loss of fatplanes between lesion IVC, third part of

doudenum
Treatment and prognosis

Management options include
endovascular aneurysm repair
(EVAR)
open surgical repair
Treatment is recommended in
surgically fit patients
if the aneurysm is
>5.0 cm diameter in women
>5.5 cm diameter in men.
growth rate exceeds 10 mm per year
in smaller aneurysms.
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What are the main causes of aortic aneurysms?

What are the main causes of aortic aneurysms?

What imaging techniques are used to diagnose aortic aneurysms and what are their advantages and limitations?

What imaging techniques are used to diagnose aortic aneurysms and what are their advantages and limitations?

Aortic Aneurysm and its

Figure 1. Anatomy of thoracic and proximal abdominal aorta.

Isselbacher E M Circulation 2005;111:816-828

Copyright American Heart Association

AAA are true aneurysms.

Figure 2. Contrast-enhanced CT scan demonstrating a 7.58.3-cm ascending thoracic aortic

CAUSES atherosclerosis(most common)

inflammatory abdominal aortic

operator dependent, bowel

Much longer acquisition time,

Bowel gas, body habitus, operator

Usg- round anoechic space defined by thick

may help detect an aneurysm rupture by

angiography has become routine for imaging

provides additional information about the

Increased Aneurysm Size

Thrombus and Calcifications

Hyperattenuating Crescent Sign

Increased Aneurysm Size:

who presents with symptoms of acute aortic

per year is also used as an indication for surgical

thus, the most common indicator for elective

Nonruptured aneurysms generally contain more

A focal discontinuity in circumferential wall

calcifications is more commonly observed in

Discontinuity of aortic wall calcifications in an abdominal aortic

increased attenuation within the

specific imaging manifestations of the

NECT (a) and contrast-enhanced (b)

1. Subtle periaortic stranding 2. Hemorrhage into posterior

CT - an aneurysm of the abdominal aorta and a large

Secondary signs of AAA

High-attenuating crescent sign in a patient with subtle evidence of

Focal discontinuity of intimal calcification

Tangential calcium sign intimal calcification points away from

be seen in a contained rupture of an

1. Draped aorta. 2. rupture

Another patient who presented with

(a rupture rate of 53%75% at surgical repair)

Uncommon (0.7%2.6% of aortic aneurysms)

Most often pseudoaneurysms.

Most commonly caused by endocarditis.

The direct spread of infection from adjacent

Majority occur in the thoracic or suprarenal

Other findings include

CT-scan shows an important infra-renal abdominal aortic

fistulas involve the duodenum,

A diagnostic dilemma for the clinician,

especially in the absence of gastrointestinal

AAA ; often with signs of rupture.

Surgical exploration is usually necessary to confirm the diagnosis

reported to occur between 2 weeks and

how an aortoesophageal fistula and intraesophageal rupture of a saccu

Inflammatory abdominal aortic

3%10% of aortic aneurysms

Predominantly found in men.