Abdominal aortic aneurysm with intramural haematoma then rupture

Case contributed by Dr Craig Hacking

Presentation

Abdominal pain. BP stable. Known AAA.

Patient Data

Age: 65-70
Gender: Male

The non contrast phase demonstrates a bilobed suprarenal AAA extending to the bifurcation with some subtle peripheral hyperdensity in the lower lobe forming a crescent concerning for intramural haematoma. There is some mild left retroperitoneal stranding. 

The CTA demonstrates eccentrically thickened aortic wall in the lower lobe of the aneurysm. No focal contrast blush is seen outside the aorta. The kidneys appear well perfused.

The patient was transferred to a tertiary centre and started to become hypotensive but responsive to packed red cells and fluids. A repeat CTA was arranged upon arrival at the tertiary centre.

CT

Repeat CTA 11 hours later after transfer to tertiary centre

There is now more left retroperitoneal stranding and fluid which is displacing the left kidney anteriorly suggesting ongoing slow rupture. In the left posterolateral wall of the lower lobe of the bilobed AAA, there is contrast now extending into the wall in keeping with progression of the acute intramural haematoma. This is at the site of the wall thickening and crescent sign on the initial CT.

No active contrast blush is seen outside the aorta. Again, the kidneys appear well perfused.

Case Discussion

The patient proceeded to surgery urgently and an open AAA repair was performed. The surgical notes describe only a thin layer of adventitia lining the intramural haematoma, with frank rupture only 'seconds away'.

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Case information

rID: 50278
Case created: 29th Dec 2016
Last edited: 11th Aug 2017
System: Vascular
Inclusion in quiz mode: Included

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