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Abdominal aortic aneurysm

Abdominal aortic aneurysms (AAA) are focal dilatations of the abdominal aorta that are 50% greater than the proximal normal segment or that are >3 cm in maximum diameter.

Epidemiology

Its prevalence increases with age. Males are much more commonly affected than females (with a male:female ratio of 4:1).

It is the tenth most common cause death in the Western world. Approximately 10% of persons older than 65 years have a AAA.

Clinical presentation

Most AAAs are asymptomatic unless they leak or rupture. Unruptured aneurysms may uncommonly cause abdominal or back pain, or a pulsatile mass, if large. 

Ruptured aneurysms present with severe abdominal or back pain, hypotension and shock. The mortality rate from a ruptured AAA is high (59-83% of patients succumb to death before they make it to hospital or undergo surgery). The operative mortality rate for those who make it to surgery tends to be around 40%. Elective surgery mortality is much lower (4-6%).

Pathology

Causes
Associations
  • common iliac artery (CIA) aneurysm
    • AAA commonly extends into common iliac arteries
    • vast majority of patients with CIA aneurysms have a AAA
    • isolated CIA aneurysms are rare
  • popliteal artery aneurysm

Radiographic features

Role of imaging
  • detection of AAA
  • monitoring of rate of growth
  • pre-operative planning
  • post-operative follow-up
Abdominal radiograph

The aneurysm may be visible as an area of curvilinear calcification in the paravertebral region on either abdominal or lumbar spine films performed for alternative indications. Radiographs are not optimal for detection or follow-up.

Ultrasound

Ultrasound assessment is simple, safe and inexpensive. It has a reported sensitivity of 95% and specificity close to 100%. It is usually the preferred choice for monitoring of small aneurysms.

CT angiography

This is considered the imaging gold standard, but has a high radiation dose. Excellent for pre-operative planning as it accurately delineates the size and shape of the AAA and its relationship to branch arteries and the aortic bifurcation. It is also superior to ultrasound in detecting and sizing common iliac artery aneurysms.

Signs of rupture or impending rupture include:

See: reporting tips for aortic aneurysms

MR angiography

Same as for CTA but can be more costly and less widely available.

DSA: angiography

Does not show true aneurysm size if there is mural thrombus but good at delineating branch vessels. Usually performed intraoperatively during treatment.  

Complications

Reported complications include:

  • rupture
  • pseudoaneurysm from chronic contained leak/rupture
  • distal thromboembolism
  • thrombotic occlusion of branch vessel
  • infection
  • compression of adjacent structures if large (rare)
  • vertebral erosion

Treatment and prognosis

The natural history of abdominal aortic aneurysms is that of slow expansion and rupture with devastating consequences.

The risk of rupture is proportional to the size of the aneurysm and the rate of growth. Differing rates of rupture for a given aneurysm size have been reported in the literature but the general consensus is that aneurysms greater than 5.0 cm in women and 5.5 to 6.0 cm in men carry a significantly increased risk of rupture and should be treated.  Furthermore, aneurysms that expand greater than 10 mm per year are also at significant risk of rupture and are considered for treatment even when less than 5.0 cm.

Follow up intervals for imaging an enlarged infrarenal abdominal aorta (when initially detected) 11:

  • <2.5 cm: follow up not needed
  • 2.5-2.9 cm: 5 year interval
  • 3.0-3.4 cm: 3 year interval
  • 3.5-3.9 cm: 2 year interval
  • 4.0-4.4 cm: 1 year interval
  • 4.5-4.9 cm: 6 month interval
  • 5.0-5.5 cm: 3-6 month interval
  • >5.5 cm: treatment

Management options include:

Treatment is recommended in surgically fit patients if the aneurysm is greater than 5.0 cm diameter in women and 5.5 cm diameter in men. Treatment is also considered if aneurysm growth rate exceeds 10 mm per year in smaller aneurysms.

Differential diagnosis


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