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.

Thank you