Rupture of abdominal aortic aneurysm
90 year-old male presenting with sudden onset lumbar pain, with radiation into the epigastrum. Hypotension and tachycardia on admission to the emergency department.
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There is a large infrarenal abdominal aortic aneurysm. The aneurysmal sac measures 80 x 70 mm in maximum axial dimensions. There is a large amount of periaortic fluid and fat stranding extending into the left side the abdomen overlying the psoas muscle, surrounding the left kidney and elevating it anteriorly, and tracking into the pelvis consistent with haemorrhage. The fluid in the left side of the abdomen measures an average density of 50 HU consistent with acute blood and there is fluid in the pelvis that demonstrates a haematocrit level. No free intraperitoneal gas to suggest perforation. There is moderate faecal loading of the colon.
Arterial phase images through the abdomen and pelvis have been obtained. There is a large fusiform infrarenal measuring 7.2 x 5.7 x 8.8 cm, extending down to the level of the aortic bifurcation. Large posterior pseudoaneurysm measures 5.0 x 1.5 x 5.3 cm. Large amount of surrounding haematoma is not significantly changed from the previous study, extending from the level of the left hemidiaphragm down to the left iliopsoas muscle. Mediolaterally, the haematoma extends from just right of the midline to the left lateroconal fascia, and anteroposteriorly from the left psoas muscle to the anterior abdominal wall. The left kidney is displacd anteriorly by the haematoma. Fusiform aneurysm of the left common iliac artery measures 2.2 cm in diameter. Bilateral common femoral artery opacify normally. Moderate amount of vessel wall calcification. Atrophic bilateral kidneys.
CONCLUSION: Large infrarenal abdominal aortic aneurysm. Large amount of periaortic fat stranding and hyperdense fluid extending into the left side the abdomen consistent with acute aneurysm rupture.
This case illustrates an infrarenal abdominal aortic aneurysm rupture.
An abdominal aortic aneurism (AAA) is defined as a permanent and irreversible localized dilatation of the abdominal aorta1. AAA rupture has an overall mortality rate of approximately 90%2, and when death ensues, it occurs due to progressive exsanguination3. Rupture of AAAs is heralded by the classic triad of sudden-onset pain in the mid-abdomen or flank (that may radiate into the scrotum), shock, and the presence of a pulsatile abdominal mass1-3. However, it is important to recognize that this triad is present in only 25–50% of patients3,4.
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- 2. Assar AN, Zarins CK. Ruptured abdominal aortic aneurysm: a surgical emergency with many clinical presentations. Postgrad Med J. 2009;85 (1003): 268-73. doi:10.1136/pgmj.2008.074666 - Pubmed citation
- 3. 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. doi:10.2214/ajr.163.5.7976888 - Pubmed citation
- 4. Creager MA, White CJ, Hiatt WR et-al. Atherosclerotic Peripheral Vascular Disease Symposium II: executive summary. Circulation. 2008;118 (25): 2811-25. doi:10.1161/CIRCULATIONAHA.108.191170 - Pubmed citation