Presentation
Pulsatile abdominal distension and hypotension.
Patient Data
A large leaking fusiform abdominal aortic true aneurysm is seen. It starts at the L2-3 level. Its neck is 4 cm inferior to the renal arteries' origin. It extends to involve the right common iliac artery. It measures 10 cm in craniocaudal extension, axial dimension 10 x 11 cm. It has a partially thrombosed lumen; remaining patent lumen with axial dimension 6.8 x 8.3 cm. Maximum thrombus thickness 4.8 cm.
Positive contrast leakage is seen through a mural defect measuring 1 cm, where contrast extravasation into aneurysmal thrombus and perianeurysmal haematoma measures 4 cm in thickness which extends to left perinephric haematoma. The left side of the retroperitoneal haematoma anterior to the left psoas muscle measures 7 cm in thickness. The posterior left pararenal space haematoma measures 3.5 cm with overall 24 cm craniocaudal dimension.
Branches: the origin of the inferior mesenteric artery is occluded by soft thrombus. Preserved origin of the coeliac, superior mesenteric and renal arteries.
Size of the normal abdominal aorta: proximal to the aneurysm; infra-renal portion of the abdominal aorta, between the aneurysm neck and renal arteries axial dimension 3.1 x 3.2 cm. Above the renal artery measures 2.7 x 2.8 cm in axial dimension.
Right common iliac artery is dilated measuring 5.5 x 5.3 cm, with partially thrombosed lumen, the patent lumen measures 2.3 x 2.6 cm. The proximal 5 cm of the left internal iliac artery is fusiform dilated measuring 2.4 cm. Left common iliac artery proximal part measures 2.0 x 1.8 cm and pre-bifurcation saccular aneurysm measures 2.7 cm. Patent external iliac arteries bilaterally with average calibre.
Multiple hepatic and renal cysts are noted. Gallbladder stones.
Case Discussion
Abdominal aortic aneurysm rupture is a complication of abdominal aortic aneurysm and is a surgical emergency. The diagnostic suggestion is based on retroperitoneal haemorrhage adjacent to the aneurysm extending to perirenal, pararenal spaces, or the psoas muscles.
On contrast CT, the active contrast extension to the periaortic haematoma is suggestive especially if it passes through the aneurysmal wall and mural thrombus. Aneurysm larger than 7 cm is at high risk of rupture. In this case, it measured 10 x 11 cm.
Treatment of an acute rupture should be prompt and can be with endovascular aneurysm repair (EVAR) or open surgery. The mortality rate is very high, >90%.
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