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Abdominal aortic aneurysm

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

Epidemiology

Abdominal aortic aneurysms represent the tenth most common cause of death in the Western world

prevalence increases with age
- ~10% of patients older than 65 years have an AAA
males are much more commonly affected than females (4:1 male/female ratio)

Clinical presentation

Since most ~~AAAs~~abdominal aortic aneurysms are asymptomatic unless they leak or rupture, they are commonly diagnosed incidentally during imaging for other indications.

Uncommonly, unruptured aneurysms may present with abdominal or back pain. Large aneurysms may present as a pulsatile abdominal mass.

Complications

The most significant complication is abdominal aortic rupture, which presents with severe abdominal or back pain, hypotension, and shock.

the mortality rate from a ruptured AAA is high
- ~70% (range 59-83%) of patients die before hospitalization or surgery
- for those who undergo operative repair, the mortality rate is ~40%
- for comparison, mortality from elective surgical repair is 4-6%
ruptured abdominal aortic aneurysms are discussed in more detail separately

Other complications include:

pseudoaneurysm from chronic contained leak/rupture
aortic fistulas
- aortocaval fistula
- aortoenteric fistula
- aorto-left renal vein fistula (very rare)
distal thromboembolism
thrombotic occlusion of a branch vessel
infection/mycotic aneurysm (actually a pseudoaneurysm)
compression of adjacent structures from large aneurysms (rare)
anterior vertebral scalloping

Pathology

Aetiology

atherosclerosis (most common)
inflammatory abdominal aortic aneurysm
chronic aortic dissection
vasculitis, e.g. Takayasu arteritis
connective tissue disorders
- Marfan syndrome
- Ehlers-Danlos syndrome
mycotic aneurysm
traumatic pseudoaneurysm
anastomotic pseudoaneurysm

Associations

common iliac artery (CIA) aneurysm
- AAA extends into the common iliac arteries in 25% of cases ¹⁴
- the vast majority of patients with CIA aneurysms have an AAA
- isolated CIA aneurysms are rare ¹⁵
popliteal artery aneurysm
- 4% of patients with an AAA have a peripheral femoral or popliteal artery aneurysm ¹⁶
- 30-50% of patients with a popliteal artery aneurysm have an AAA
intracranial cerebral aneurysm
- prevalence of ~10%, higher in females ¹³

Radiographic features

Role of imaging includes

detection of AAA
monitoring of growth rate
preoperative planning
postoperative follow-up

Plain radiograph

An aneurysm may be visible as an area of curvilinear calcification in the paravertebral region on either abdominal or lumbar spine radiographs. Although not adequate for AAA detection or follow-up, an x-ray may be sufficient for initial detection and diagnosis.

Ultrasound

Ultrasound is optimal for general AAA screening and surveillance, because it is fast, spares the use of ionizing radiation and intravenous contrast, and is relatively inexpensive. The sensitivity and specificity approach 100% ¹⁹; however, it should be noted that visualization is poor in 1% to 3% of patients due to patient habitus or overlying bowel gas ¹⁹.

Although excellent for following lesions, ultrasound does not provide sufficient detail for procedural planning or more complex lesions. Given a reported range in the measurement error of 4 mm ¹², ultrasound cannot be reliably used in evaluation for endovascular treatments and assessment of regional branch vessels.

CT

CT angiography (CTA) is considered the gold standard for evaluation but exposes the patients to high radiation doses. It is 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. Oblique reformations enable accurate measurements in non-orthogonal planes. CTA is superior to ultrasound in detecting and measuring common iliac artery aneurysms.

Signs of frank rupture include:

retroperitoneal haematoma
para-aortic fat stranding
contrast extravasation from the aorta into the retroperitoneum

Signs of impending rupture or contained leakage:

draped aorta sign (contained rupture)
high-attenuation crescent sign
thrombus fissuration
focal discontinuity of intimal calcification
tangential calcium sign

An increasing diameter of the aneurysmal sac of 5 mm over a 6-month interval or a diameter of 7 cm are also considered to be at high risk for rupture and warrant urgent repair.

Dual-energy CT

Imaging of aortic aneurysms with dual-energy CT can be used to discern the difference between iodinated contrast, calcified atheroma, and previous grafts or surgical materials. Post-processing techniques can create virtual non-calcium or non-enhanced images. Dual-energy CT has several advantages over single-energy CT including delivering lower radiation doses, lower volumes of contrast, removing calcified plaques from the image to allow assessment of the degree of stenosis, and allows better assessment of endoleak ²².

Angiography (DSA)

Catheter-based angiography alone is inadequate for the pre-procedural evaluation of AAA. While digital subtraction angiography (DSA) is superb for delineating regional branch vessels, it can be misleading and mask true aneurysm size in the setting of mural thrombus.

MRI

MR angiography offers a lack of ionising radiation but is more costly, less widely available, and the examination is substantially lengthier.

Radiology report

Certain features and relevant negatives regarding AAA should be included in the radiology report - especially if this is a new or undocumented finding:

morphology
- maximum transverse diameter of the aneurysmal sac
  - must be measured perpendicular to the longitudinal aortic axis
  - keep in mind that an aneurysm never decreases in size!
- longitudinal length
- shape (saccular/fusiform/eccentric)
- any major kink
- upper extent, relative to the renal arteries
- lower extent, including extension into any branches
- any side or visceral branches arising from the aneurysm
complications
- signs of impending rupture
- branch-vessel dissection
- end vessel infarct (e.g. renal or splenic infarct)
relevant anatomy
- diameters of the common femoral artery (CFA) and external iliac artery (EIA) for the planning of endovascular treatment
- presence of aberrant renal veins (e.g. retroaortic or circumaortic left renal vein)
- presence of accessory renal arteries

Also see: reporting tips for aortic aneurysms

Treatment and prognosis

The natural history of abdominal aortic aneurysms is variable; some small aneurysms do not appear to change, while others slowly expand and become at risk for eventual rupture ^19,21. A number of clinical factors (e.g. smoking, gender, blood pressure) are known to contribute. Ultimately, the primary clinical question is whether and when to intervene to avoid aortic rupture.

In terms of imaging, there remains debate about the best criteria for predicting AAA rupture and therefore indications for operative intervention. Prognostic imaging criteria include:

maximum transverse diameter
- most widely used and validated method ^19,20
- 2018 Society of Vascular Surgery recommendations generally recommend intervention for AAA ≥5.4 cm, and surveillance for smaller diameter lesions ¹⁹
- young, healthy (especially female) patients may benefit from intervention for lesions between 5.0 - 5.4 cm ¹⁹
- most study data is based on fusiform aneurysms; it is debated whether the more uncommon saccular aneurysm is at higher risk for rupture at smaller transverse diameter ¹⁹
rate of aneurysm growth
- enlargement in transverse diameter ≥5 mm in 6 months may be an indication for intervention ¹⁷
symptomatic lesions ¹⁹

In patients with a connective tissue disorder (e.g. Marfan syndrome), especially those with a bicuspid aortic valve, surgical treatment may be considered even with a diameter smaller than 5.0 cm.

Recommended imaging follow-up intervals for enlarged infrarenal abdominal aorta vary by organization. The American College of Radiology (2013) recommends 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

The Society for Vascular Surgery (2018) recommends ¹⁹:

>2.5-2.9 cm: rescreen after 10 years
3.0-3.9 cm: 3-year interval
4.0-4.9 cm: 1-year interval
5.0-5.4 cm: 6-month interval

Management options include:

surveillance (see above)
endovascular aneurysm repair (EVAR) ²³
- if the anatomy permits, EVAR is preferred because of its less invasive nature vs open surgical repair
- aneurysm-related mortality is much lower with EVAR vs open surgical repair
resection (open surgical repair)

Differential diagnosis

aortic dissection

-<p><strong>Abdominal aortic aneurysms (AAA)</strong> are focal dilatations of the abdominal aorta measuring 50% greater than the proximal normal segment, or >3 cm in maximum diameter.</p><h4>Epidemiology</h4><ul>
~~-<li>represent the tenth most common cause of death in the Western world</li>~~
+<p><strong>Abdominal aortic aneurysms (AAA)</strong> are focal dilatations of the abdominal aorta measuring 50% greater than the proximal normal segment, or >3 cm in maximum diameter.</p><h4>Epidemiology</h4><p>Abdominal aortic aneurysms represent the tenth most common cause of death in the Western world:</p><ul>
-</ul><h4>Clinical presentation</h4><p>Since most AAAs are asymptomatic unless they leak or rupture, they are commonly diagnosed incidentally during imaging for other indications.</p><p>Uncommonly, unruptured aneurysms may present with abdominal or back pain. Large aneurysms may present as a pulsatile abdominal mass.</p><h5>Complications</h5><p>The most significant complication is <a href="/articles/ruptured-abdominal-aortic-aneurysm">abdominal aortic rupture</a>, which presents with severe abdominal or back pain, hypotension, and shock.</p><ul>
+</ul><h4>Clinical presentation</h4><p>Since most abdominal aortic aneurysms are asymptomatic unless they leak or rupture, they are commonly diagnosed incidentally during imaging for other indications.</p><p>Uncommonly, unruptured aneurysms may present with abdominal or back pain. Large aneurysms may present as a pulsatile abdominal mass.</p><h5>Complications</h5><p>The most significant complication is <a href="/articles/ruptured-abdominal-aortic-aneurysm">abdominal aortic rupture</a>, which presents with severe abdominal or back pain, hypotension, and shock.</p><ul>
-</ul><p>Also see: <a href="/articles/reporting-tips-for-aortic-aneurysms">reporting tips for aortic aneurysms</a></p><h4>Treatment and prognosis</h4><p>The natural history of abdominal aortic aneurysms is variable; some small aneurysms do not appear to change, while others slowly expand and become at risk for eventual rupture <sup>19,21</sup>. A number of clinical factors (e.g. smoking, gender, <a title="Blood pressure" href="/articles/blood-pressure">blood pressure</a>) are known to contribute. Ultimately, the primary clinical question is whether and when to intervene to avoid aortic rupture.</p><p>In terms of imaging, there remains debate about the best criteria for predicting AAA rupture and therefore indications for operative intervention. Prognostic imaging criteria include:</p><ul>
+</ul><p>Also see: <a href="/articles/reporting-tips-for-aortic-aneurysms">reporting tips for aortic aneurysms</a></p><h4>Treatment and prognosis</h4><p>The natural history of abdominal aortic aneurysms is variable; some small aneurysms do not appear to change, while others slowly expand and become at risk for eventual rupture <sup>19,21</sup>. A number of clinical factors (e.g. smoking, gender, <a href="/articles/blood-pressure">blood pressure</a>) are known to contribute. Ultimately, the primary clinical question is whether and when to intervene to avoid aortic rupture.</p><p>In terms of imaging, there remains debate about the best criteria for predicting AAA rupture and therefore indications for operative intervention. Prognostic imaging criteria include:</p><ul>

References changed:

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1. Pande RL, Beckman JA. Abdominal aortic aneurysm: populations at risk and how to screen. J Vasc Interv Radiol. 2008;19 (6 Suppl): S2-8. <a href="http://dx.doi.org/10.1016/j.jvir.2008.03.010">doi:10.1016/j.jvir.2008.03.010</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/18502382">Pubmed citation</a><div class="ref_v2"></div>
2. Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate. J. Vasc. Surg. 2003;37 (2): 280-4. <a href="http://dx.doi.org/10.1067/mva.2003.119">doi:10.1067/mva.2003.119</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/12563196">Pubmed citation</a><div class="ref_v2"></div>
3. Kaufman JA, Lee MJ. Vascular and interventional radiology, the requisites. Mosby Inc. (2004) ISBN:0815143699. <a href="http://books.google.com/books?vid=ISBN0815143699">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0815143699?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0815143699">Find it at Amazon</a><div class="ref_v2"></div>
4. Wright LB, Matchett WJ, Cruz CP et-al. Popliteal artery disease: diagnosis and treatment. Radiographics. 24 (2): 467-79. <a href="http://dx.doi.org/10.1148/rg.242035117">doi:10.1148/rg.242035117</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/15026594">Pubmed citation</a><div class="ref_v2"></div>
5. Rakita D, Newatia A, Hines JJ et-al. Spectrum of CT findings in rupture and impending rupture of abdominal aortic aneurysms. Radiographics. 27 (2): 497-507. <a href="http://dx.doi.org/10.1148/rg.272065026">doi:10.1148/rg.272065026</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/17374865">Pubmed citation</a><div class="ref_v2"></div>
6. Siegel CL, Cohan RH, Korobkin M et-al. Abdominal aortic aneurysm morphology: CT features in patients with ruptured and nonruptured aneurysms. AJR Am J Roentgenol. 1994;163 (5): 1123-9. <a href="http://www.ajronline.org/cgi/content/citation/163/5/1123">AJR Am J Roentgenol (citation)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/7976888">Pubmed citation</a><div class="ref_v2"></div>
7. Schwartz SA, Taljanovic MS, Smyth S et-al. CT findings of rupture, impending rupture, and contained rupture of abdominal aortic aneurysms. AJR Am J Roentgenol. 2007;188 (1): W57-62. <a href="http://dx.doi.org/10.2214/AJR.05.1554">doi:10.2214/AJR.05.1554</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/17179328">Pubmed citation</a><div class="ref_v2"></div>
8. Roy J, Labruto F, Beckman MO et-al. Bleeding into the intraluminal thrombus in abdominal aortic aneurysms is associated with rupture. J. Vasc. Surg. 2008;48 (5): 1108-13. <a href="http://dx.doi.org/10.1016/j.jvs.2008.06.063">doi:10.1016/j.jvs.2008.06.063</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/18771882">Pubmed citation</a><div class="ref_v2"></div>
9. Apter S, Rimon U, Konen E et-al. Sealed rupture of abdominal aortic aneurysms: CT features in 6 patients and a review of the literature. Abdom Imaging. 2010;35 (1): 99-105. <a href="http://dx.doi.org/10.1007/s00261-008-9488-1">doi:10.1007/s00261-008-9488-1</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/19082650">Pubmed citation</a><div class="ref_v2"></div>
10. Lai CC, Tan CK, Chu TW et-al. Chronic contained rupture of an abdominal aortic aneurysm with vertebral erosion. CMAJ. 2008;178 (8): 995-6. <a href="http://www.cmaj.ca/content/178/8/995.full">CMAJ (full text)</a> - <a href="http://dx.doi.org/10.1503/cmaj.070332">doi:10.1503/cmaj.070332</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276548">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/18390941">Pubmed citation</a><span class="ref_v3"></span>
11. Khosa F, Krinsky G, Macari M et-al. Managing incidental findings on abdominal and pelvic CT and MRI, Part 2: white paper of the ACR Incidental Findings Committee II on vascular findings. J Am Coll Radiol. 2013;10 (10): 789-94. <a href="http://dx.doi.org/10.1016/j.jacr.2013.05.021">doi:10.1016/j.jacr.2013.05.021</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/24091049">Pubmed citation</a><span class="auto"></span>
12. Singh K, Bønaa KH, Solberg S et-al. Intra- and interobserver variability in ultrasound measurements of abdominal aortic diameter. The Tromsø Study. Eur J Vasc Endovasc Surg. 1998;15 (6): 497-504. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9659884">Pubmed citation</a><span class="auto"></span>
13. Rouchaud A, Brandt MD, Rydberg AM et-al. Prevalence of Intracranial Aneurysms in Patients with Aortic Aneurysms. AJNR Am J Neuroradiol. <a href="http://dx.doi.org/10.3174/ajnr.A4827">doi:10.3174/ajnr.A4827</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/27256853">Pubmed citation</a><span class="auto"></span>
14. Olsen PS, Schroeder T, Agerskov K, Røder O, Sørensen S, Perko M, Lorentzen JE. Surgery for abdominal aortic aneurysms. A survey of 656 patients. The Journal of cardiovascular surgery. 32 (5): 636-42. <a href="https://www.ncbi.nlm.nih.gov/pubmed/1939327">Pubmed</a> <span class="ref_v4"></span>
15. Brunkwall J, Hauksson H, Bengtsson H, Bergqvist D, Takolander R, Bergentz SE. Solitary aneurysms of the iliac arterial system: an estimate of their frequency of occurrence. Journal of vascular surgery. 10 (4): 381-4. <a href="https://www.ncbi.nlm.nih.gov/pubmed/2795762">Pubmed</a> <span class="ref_v4"></span>
16. Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Archives of surgery (Chicago, Ill.). 105 (2): 338-44. <a href="https://www.ncbi.nlm.nih.gov/pubmed/5044555">Pubmed</a> <span class="ref_v4"></span>
17. Lederle FA, Wilson SE, Johnson GR, Reinke DB, Littooy FN, Acher CW, Ballard DJ, Messina LM, Gordon IL, Chute EP, Krupski WC, Busuttil SJ, Barone GW, Sparks S, Graham LM, Rapp JH, Makaroun MS, Moneta GL, Cambria RA, Makhoul RG, Eton D, Ansel HJ, Freischlag JA, Bandyk D. Immediate repair compared with surveillance of small abdominal aortic aneurysms. The New England journal of medicine. 346 (19): 1437-44. <a href="https://doi.org/10.1056/NEJMoa012573">doi:10.1056/NEJMoa012573</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/12000813">Pubmed</a> <span class="ref_v4"></span>
18. Kent KC. Endovascular aneurysm repair--is it durable?. The New England journal of medicine. 362 (20): 1930-1. <a href="https://doi.org/10.1056/NEJMe1004299">doi:10.1056/NEJMe1004299</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20484400">Pubmed</a> <span class="ref_v4"></span>
19. Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, Mastracci TM, Mell M, Murad MH, Nguyen LL, Oderich GS, Patel MS, Schermerhorn ML, Starnes BW. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. (2018) Journal of vascular surgery. 67 (1): 2-77.e2. <a href="https://doi.org/10.1016/j.jvs.2017.10.044">doi:10.1016/j.jvs.2017.10.044</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29268916">Pubmed</a> <span class="ref_v4"></span>
20. Darling RC, Messina CR, Brewster DC, Ottinger LW. Autopsy study of unoperated abdominal aortic aneurysms. The case for early resection. (1977) Circulation. 56 (3 Suppl): II161-4. <a href="https://www.ncbi.nlm.nih.gov/pubmed/884821">Pubmed</a> <span class="ref_v4"></span>
21. Thompson AR, Cooper JA, Ashton HA, Hafez H. Growth rates of small abdominal aortic aneurysms correlate with clinical events. (2010) The British journal of surgery. 97 (1): 37-44. <a href="https://doi.org/10.1002/bjs.6779">doi:10.1002/bjs.6779</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20013940">Pubmed</a> <span class="ref_v4"></span>
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26","thumbnail":"https://prod-images-static.radiopaedia.org/images/5046952/71187c56646e7aa4adba762bac1a61_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":5072774,"studyId":26001,"caseSlug":"abdominal-aortic-aneurysm-20","caption":"Case 27","thumbnail":"https://prod-images-static.radiopaedia.org/images/5072774/cecbbfeaf3169fce7ee653e5177efd_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":5156655,"studyId":26121,"caseSlug":"abdominal-aortic-aneurysm-24","caption":"Case 28","thumbnail":"https://prod-images-static.radiopaedia.org/images/5156655/d163920896cbcd09672c6b791d857193497d3778309ab57eae70b60e18bf3e92_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":5159649,"studyId":24752,"caseSlug":"abdominal-aortic-aneurysm-18","caption":"Case 29: on plain 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