Presentation
Sudden onset of severe bilateral lower limbs and hip pain with dusky discolouration of bilateral toes.
Patient Data
Minimal degree of mural calcifications seen at the abdominal aorta and bilateral common iliac arteries, but worst at the left common iliac artery.
On plain study, hyperintense intraluminal content within the infrarenal abdominal aorta which can represent acute blood clot/thrombus/embolus.
On arterial phase, abrupt cut off of the contrast opacification at the infrarenal part of the abdominal aorta (at the upper border of L3 vertebra). The cut off denotes complete occlusion where the distal part of abdominal aorta, bilateral common iliac arteries and proximal halves of the bilateral external iliac arteries are not opacified with contrast.
However, distal reconstitution of contrast opacification seen at distal halves of bilateral external iliac arteries and their bilateral distal branches (namely common femoral arteries, superficial femoral arteries, profunda femoris arteries, popliteal arteries, tibioperoneal trunk, anterior tibial arteries, posterior tibial arteries, peroneal arteries and dorsalis pedis) are opacified from collateral arterial supplies of bilateral epigastric arteries. The left distal lower limb arterial branches are opacified in lesser degree enhancement comparing to the right side (faint contrast enhancement from left mid superficial femoral artery onwards) No significant mural calcification or thrombus seen in bilateral lower limb arteries.
The celiac trunk, superior mesenteric artery, inferior mesenteric artery and bilateral renal arteries are well opacified and normal in caliber.
The bilateral internal iliac arteries are opacified via reconstitution collateral supply via the inferior mesenteric artery at anastomosis of rectal arteries.
Within the limitation of plain study, two well-defined hypodense lesions seen at segment IVa and segment V of liver measuring 0.8 x 0.8cm and 1.2x1.6cm (APxW) respectively. No intrahepatic duct dilatation.
Serpiginous sclerotic medullary bone lesion in bilateral distal one-third of femurs and left proximal tibia without abnormal periosteal reaction. No suspicious bone lesion.
Case Discussion
Acute total occlusion of the infrarenal abdominal aorta with distal reconstitution of bilateral lower limbs arteries from epigastric arteries (faint opacification at arteries distal to left mid superficial femoral arteries). This can be caused by thrombus or embolus lodged at the infrarenal abdominal aorta. The differentiation from imaging point of view is difficult. No obvious major organ ischemia.
The blood investigation showed marked increase of creatine kinase (CK), which may support the occlusion of artery is acute event.
Bilateral distal femur and left proximal tibial osteonecrosis/bone infarcts.
Knowing the basic artery anatomy is crucial to determine the possible collateral supply.
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