AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Background

Approximately 40,000 patients undergo aneurysmorrhaphy each year. In the United States, 15,000 deaths per year are attributed to abdominal aortic aneurysms (AAAs).

Since 1951, when Dubost first performed repair of an AAA with a homograft, surgery has been the mainstay of treatment. Many refinements in technique have occurred during the interval, but none as significant as the stent-graft. In 1991, Parodi et al described a novel, less invasive technique for repairing AAAs by placing a graft from within the vessel. This technique was labor intensive and involved the customized construction of the graft for each patient by sewing the graft material to self-expanding metal skeleton. Today, designs are approved by the US Food and Drug Administration, and numerous devices are being used in clinical investigations.^{1, 2, 3, 4, 5}

Related eMedicine topics:
Aneurysm, Abdominal (Emergency Medicine)
Abdominal Aortic Aneurysm, Rupture
Abdominal Aortic Aneurysm (Vascular Surgery)

Related Medscape topics:
Radiology CME and News
CE  Thoracoaortic Aneurysms and Dissections: Guidance for the Primary Care Clinician
CME  Screening for Aortic Aneurysms in Older Men Decreases Mortality
CME  VEITHSymposium 2007: Stronger Evidence, More Acceptance for Endovascular Repair of Aortic Aneurysms
CME  Severe Aortic and Arterial Aneurysms Associated With a TGFBR2 Mutation

Pathophysiology

Classically, abdominal aortic aneurysms (AAAs) have been attributed to a weakening of the arterial wall as a result of atherosclerotic vascular disease caused by the atheromatous lesions seen on pathologic examination. Recent evidence supports a multifactorial process in which atherosclerosis is involved. Other etiologic cofactors under investigation include changes in the matrix of the aortic wall with age, proteolysis, metalloproteinase changes, inflammation, infectious agents (eg, syphilis, mycotic infections), and a genetic predisposition (eg, Marfan syndrome, Ehlers-Danlos syndrome).^{5, 6, 7}

True aneurysms involve dilation of all 3 layers of the vessel wall, whereas false aneurysms are caused by the disruption of 1 or more layers of the vessel wall. Elastin and collagen are the primary structural elements of the aortic wall. Experimental findings have shown that the relative content of elastin and collagen are lowest in the infrarenal aorta and that, with the destruction of collagen and elastin, dilatation of the aorta ensues. Increased concentrations of several proteases capable of degrading collagen and/or elastin have been found in the walls of AAAs and in aortic occlusive disease; both are manifestations of atherosclerosis.

An immunologic component to atherosclerotic vascular disease has been recognized and is characterized by infiltration of the aortic wall by macrophages, T lymphocytes, and B lymphocytes; these are known to activate proteolytic activity. The nature of this response has led researchers to investigate autoimmunity in the pathogenesis of AAA. Reports describe Chlamydia pneumoniae antigens, in contrast to active infection, in the walls of AAA. After the infectious agent is cleared, an antigenic stimulus remains, stimulating proteolytic activity with weakening of the vessel wall and aneurysm formation.

Inflammatory aneurysms, once believed to be distinct entities, are currently considered one extreme in the spectrum of atherosclerotic aneurysms; these account for 3-10% of all AAAs. Clinical and imaging characteristics differentiate inflammatory from noninflammatory aneurysms.⁸

The familial pattern of AAA has long been recognized with a 15-19% incidence among first-degree relatives. This observation suggests that one or more genes are related to AAA and atherosclerosis. The identification of these genes may enable the early detection and prevention of AAA in high-risk patients.⁹

Frequency

United States

Abdominal aortic aneurysms (AAAs) are usually asymptomatic and detected on routine physical examination or during an unrelated radiologic examination. Therefore, the condition is likely underdiagnosed. In most studies, prevalence increases in those older than 60 years. In the United States, the reported incidence is 5-7% with a mean patient age of 70-75 years.

International

In Europe and Asia, the reported incidence of abdominal aortic aneurysms (AAAs) is 5-7%, with a mean patient age of 70-75 years.

Mortality/Morbidity

In the United States 15,000 deaths per year are attributed to abdominal aortic aneurysms (AAAs).

• When AAAs are repaired electively, the overall mortality rate is 0.9-5%.
• If repair is delayed until rupture, mortality rates as high as 75% are reported.^{10, 11}
• In aneurysms 4-5 cm in diameter, the risk of rupture is almost 25%, with an associated mortality rate as high as 75%.

Race

• Worldwide, abdominal aortic aneurysms (AAAs) are more common in white males than in others. In the United States, AAA is far more common in white males than in black males. This difference may be partially caused by increased detection in white males, resulting from better access to medical care.
• The prevalence in white and black females is almost identical.
• Etiologic explanations for these race-related differences include different genetic susceptibility, as well as exposure to environmental risk factors. Note that, in the United States, other clinical manifestations of atherosclerosis do not have this racial predilection.

Sex

Depending on the published series, the male-to-female ratio is 1.6-4.5:1.¹²

• Inflammatory aneurysms represent 3-10% of atherosclerotic abdominal aortic aneurysms (AAAs) and have a male-to-female ratio of 6-30:1.
• The reasons for male preponderance of AAA are not clear; however, hormonal factors, genetic susceptibility, and exposure to environmental factors are believed to play a role.

Age

• Abdominal aortic aneurysms (AAAs) occur in 5-7% of the population older than 60 years.
• AAAs are seen most often in patients aged 60-80 years.
• The mean age of patients with inflammatory aneurysms is 62-65 years; these patients are 5-10 years younger than those with noninflammatory AAA.

Anatomy

An aneurysm is defined as a localized dilation of an artery by at least 50% as compared with the expected normal diameter of the vessel. The term ectasia is used when the dilatation is less than 50%. If the arteries are diffusely enlarged by 50% or more, the condition is called arteriomegaly.^{13, 14}

The Society for Vascular Surgery and the International Society for Cardiovascular Surgery have suggested the classification of aneurysms by their site, origin, histologic features, and clinicopathologic manifestations. The anatomic site and morphology of an aneurysm can be preoperatively determined by radiologic means.^{15, 16, 17}

The site of an aneurysm is related to its natural history, clinical presentation, and means of treatment. The site of abdominal aneurysms should be characterized as suprarenal, juxtarenal or pararenal, or infrarenal. Approximately 90-95% of abdominal aortic aneurysms (AAAs) involve the infrarenal abdominal aorta. Rarely do they extend above the renal arteries; however, extension into the common iliac arteries is fairly common.

Clinical Details

Abdominal aortic aneurysms (AAAs) occur in 5-7% of the population older than 60 years. Although most patients with AAA are asymptomatic, they can present with symptoms of mass effect, compression of abdominal organs, or visceral or peripheral emboli originating from the wall of the aneurysm. Rarely, patients present with back pain, which can represent rupture of the aneurysm, a surgical emergency. Patients older than 60 years who smoke and who are known to have atherosclerosis, hypertension, and/or chronic obstructive pulmonary disease are at increased risk for AAA. Routine screening of these patients is warranted.

Once an aneurysm is identified, it should be repaired or followed up with imaging, depending on the clinical scenario and the size of the aneurysm at the time of diagnosis. Most aneurysms (80%) demonstrate progressive enlargement. The diameter of an aneurysm is directly related to its risk of rupture. For aneurysms smaller than 4 cm in diameter, the risk of rupture is less than 10%. Once an aneurysm is 4-5 cm in diameter, the risk of rupture increases to almost 25%, with an associated mortality rate as high as 75%. The accepted surgical mortality rate remains less than 5% with the elective repair of these 4- to 5-cm aneurysms.

The morphologic features, including the maximum diameter in both the anteroposterior and lateral dimensions and the length of the aneurysm, should be reported. The shape of the aneurysm (fusiform or saccular) and its relationship to branch vessels should be described. Arterial wall complications such as the expansion over time, compression or erosion into adjacent structures, rupture, dissection, and thrombotic occlusion should be documented as well.

With the advent of the endoluminal repair of aneurysms, several additional morphologic characteristics should be recorded. These determine if endovascular repair is possible, and if so, what type of device can be used. These features include the following: (1) greatest mural diameter, (2) extent of aneurysm (eg, length of proximal and distal neck, extension into iliac arteries), (3) tortuosity of the aorta, (4) anatomy of the iliac arteries (eg, iliac artery occlusive disease, tortuosity, caliber, patency of internal iliac arteries and relation of aneurysm to them, presence of concomitant iliac artery aneurysms), (5) presence and degree of intraluminal thrombus, (6) presence and degree of calcification in the neck and iliac arteries, and (7) anatomy of the femoral arteries (eg, caliber, degree of calcification or occlusive disease).

Preferred Examination

Because of portability, lack of ionizing radiation, cost, and availability, ultrasonography (US) should be the initial imaging modality when an asymptomatic, pulsatile abdominal mass is palpated.

If the aneurysm is approaching 5 cm or more or if rapid enlargement is seen on serial US images, a CT or CT angiogram (CTA) should be ordered to better delineate the extent of disease prior to conventional surgery or treatment with the insertion of an endovascular graft. In patients whose renal function does not permit the administration of iodinated contrast material, MRI and magnetic resonance angiography (MRA) provide good alternatives.

Angiographic examination may be requested because of a clinical concern that concomitant renal artery stenosis or peripheral vascular disease may require surgical intervention during repair of abdominal aortic aneurysms (AAAs). At some institutions, CTA and MRA have replaced routine diagnostic angiography in the preoperative evaluation of AAA.

In urgent situations in which the clinical diagnosis is fairly certain or rupture is imminent or suspected and in which the patient's condition is stable, CT and/or CTA may be the initial and only examination required.

Imaging of the aorta does not end with the repair of the aneurysm. After repair with either a traditional open surgical procedure or an endovascular procedure, follow-up imaging is necessary. In the case of conventional surgical repair, follow-up imaging is performed yearly, usually with US. For endovascular grafts, the follow-up is more stringent, with immediate postprocedural CT as well as 6-month and then yearly CT follow-up.

When the evaluation for AAA is performed with CT or MRI, note the extent of the aneurysm, any involvement of major branch vessels, and the existence of a retroaortic or circumaortic left renal vein. Note if the aneurysm has significant wall thickening, a typical characteristic of an inflammatory aneurysm, because the surgical approach for this condition differs from that needed for the more common, predominantly atherosclerotic aneurysm.

Limitations of Techniques

With conventional radiography in the anteroposterior or lateral projection, calcification of both opposing abdominal aortic walls must be present to outline abdominal aortic aneurysms (AAAs). However, this finding is present in less than 50% of cases. A tortuous, calcified aorta may mimic an AAA unless both walls can be seen clearly. The lack of overlying bony structures in the lateral projection may allow clearer definition of the aneurysm.

US is considered the screening examination of choice; however, it may not adequately depict the entire abdominal aorta if a large amount of bowel gas is present or if the patient is obese.

With or without contrast enhancement, CT is an excellent screening examination for AAA. CT depicts the absolute size of the aneurysm. However, the extent of mural thrombus and the presence of dissection cannot be evaluated without the administration of contrast material.

MRI with contrast enhancement provides an alternative to CT in patients with renal insufficiency. MRI has several absolute contraindications, including cardiac pacemakers and intracranial aneurysm clips. Claustrophobia and a patient's inability to remain motionless are likely to yield a nondiagnostic study. MRI is not as available as CT and US.

Angiography is also a safe procedure. However, because it is an invasive procedure, a small but definite risk to the patient exists. The true size of the aneurysm may not be discernible because of a mural thrombus; therefore, underestimation of the true extent of the aneurysm is possible. The role of angiography is in planning surgical or endovascular repair.

Patient Education: For excellent patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education article Aortic Aneurysm.

DIFFERENTIALS

Section 3 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Other Problems to be Considered

Inflammatory aneurysm
Mycotic aneurysm
Penetrating ulcer

RADIOGRAPH

Section 4 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Findings

Calcification of the abdominal aortic wall is frequently evident on plain radiographs of the abdomen. Calcification is best seen on lateral views when the spine does not obscure the opposing walls of the vessel. When calcification can be clearly identified in the opposing aortic walls, abdominal aortic aneurysms (AAAs) can be diagnosed with the plain radiographic findings.

Degree of Confidence

If the classic eggshell appearance is present (see Image 2), the degree of confidence is approximately 100%; however, this finding is present only in 50% of patients. Occasionally, only the anteroposterior or lateral abdominal image demonstrates the findings clearly. If abdominal aortic aneurysms (AAAs) are suspected, perform abdominal US or CT for confirmation. As such, negative plain radiographic findings do not exclude the diagnosis in any way.

False Positives/Negatives

A tortuous, calcified aorta can mimic abdominal aortic aneurysm (AAA) unless both walls can be seen clearly. If the opposing walls are not calcified, the diagnosis cannot be made with certainty. In these cases, US, CT, or MRI must be performed if AAA is clinically suspected.

CT SCAN

Section 5 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Findings

CT accurately demonstrates dilation of the aorta (see Image 3) and involvement of major branch vessels proximally and distally. This information helps in determining the appropriate intervention, which may be either surgical or endovascular repair. CT also shows the other organs in the abdomen and demonstrates involvement or displacement of organs that can confuse the clinical picture. The location and number of the renal arteries, caliber of the aneurysm, degree of calcification, lengths of the neck and iliac artery, and presence of mural thrombus are readily assessed. CTA allows multiplanar assessment of the aneurysm and associated relevant vessels (visceral arteries, iliac and femoral arteries).

Degree of Confidence

CT has emerged as the diagnostic imaging standard for the evaluation of AAA with an accuracy that approaches 100%. A well-performed CT examination can reveal the extent of the aneurysm, as well as the involvement of other organs. Intravenously administered contrast agent is needed to obtain the full benefit of CT; however, a nonenhanced study accurately depicts AAAs. Three-dimensional reconstructions of state-of-the-art, multidetector-row, helical CT scans can help in preoperative planning and may replace the need for preoperative diagnostic angiography.

False Positives/Negatives

The administration of contrast material is essential for detecting dissection or ulceration of a vessel that might be missed without it. In the acute setting (eg, in a patient with back pain or an aneurysm), a false-positive diagnosis of rupture is possible if fluid resulting from another cause is seen in the abdomen. Conversely, an aneurysm or rupture can be missed in a patient who has recently undergone barium study because artifact can obscure the aorta.

MRI

Section 6 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Findings

MRI and MRA can be used to define the extent of abdominal aortic aneurysms (AAAs) (see Image 8). The absence of iodinated contrast material and radiation are advantages of this modality. However, MRI is more sensitive to motion than CT because a patient must remain motionless for longer than with current multidetector-row helical CT technology. In addition, the remaining organs in the abdomen are not seen as well on MRIs because of motion.

Degree of Confidence

In technically well performed MRI and MRA, degree of confidence approaches 100%. These examinations clearly reveal the extent of the aneurysm; however, motion can cause artifacts that can render the results nondiagnostic. Patients must be able to remain motionless for longer periods than with CT to enable a diagnostic examination.

False Positives/Negatives

If prior abdominal surgery has been performed and if metal clips or devices were used, MRI may not be possible. If the metal is close to the aneurysm or if branch vessels or heavy calcification is seen, artifacts may obscure the vessel and result in a nondiagnostic study.

ULTRASOUND

Section 7 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Findings

US is the screening examination of choice as a result of its relative availability, speed, and low cost (see Image 7). US is operator dependent, unlike other modalities; therefore, operator experience is important. The abdominal aorta normally tapers as it extends distally. Any increase in its diameter is considered abnormal.

Degree of Confidence

If the abdominal aorta can be seen in its entirety, US provides a reliable, low-cost screening examination. Any increase in the size as the aorta travels distally is abnormal. However, in a patient who is obese or in whom the bowel is distended with gas, a complete examination of the aorta and proximal iliac arteries may not be technically possible. In such instances, another cross sectional imaging study (eg, CT, MRI) should be obtained.

False Positives/Negatives

A technically unsatisfactory examination may result from a large patient body habitus or a large amount of bowel gas, which results in incomplete visualization of the aorta. Thus, a false-negative result is possible if these limitations are not recognized.

ANGIOGRAPHY

Section 8 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Findings

Angiography is often ordered for preoperative evaluation in patients with manifestations of atherosclerotic vascular disease such as renal artery stenosis or peripheral vascular disease.

Compared with other images, arteriograms currently enable better longitudinal measurements of aneurysms. The reason is that the catheters that are used to make these measurements follow the contour of the vessels and therefore allow better determination of the length of the aneurysm, as opposed to linear measurements obtained with CT. This information is not an issue for open surgical repair; however, it is important in endovascular repair. Catheters with radiopaque graduated markers are used, allowing measurement of the lengths of the aneurysm and the caliber of the vessel. These data are occasionally important for endograft placement, and they may not be clear from CT and CTA. Typically, 7-10 measurements are required to size an endovascular graft to an abdominal aortic graft. Much if not all of the sizing can be accomplished with thin-section contrast-enhanced CTA.

As CT algorithms for measuring aneurysms improve, the need for preoperative angiography will decrease. Angiography may be reserved for the most complex aneurysms in which endovascular repair is contemplated.

Angiography is often linked to embolization of the internal iliac artery in a patient in whom the procedure is necessary prior to endovascular repair. Examples of relevant conditions include an internal iliac artery aneurysm or an ectatic aneurysm ipsilateral to a common iliac artery that requires anchoring of the stent-graft in the ipsilateral external iliac artery.

Degree of Confidence

When abdominal aortic aneurysm (AAA) is suspected, it is unlikely to be missed at angiography. In most cases, the morphology of an aneurysm can be clearly defined. If an aneurysm is suspected on the arteriogram, a cross sectional image should be obtained. Not only will it confirm the existence of an aneurysm, but other pathologic conditions that may affect the surgical intervention can be detected.

False Positives/Negatives

If a large amount of luminal thrombus is present, the true diameter of the aneurysm may be obscured unless the wall of the aneurysm has a substantial amount of calcification. This limitation leads to significant underestimation of the diameter of the aneurysm.

INTERVENTION

Section 9 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

The Society for Vascular Surgery and the International Society for Cardiovascular Surgery guidelines for the repair of abdominal aortic aneurysms (AAAs) include the following: (1) Any patient with a documented rupture or suspected rupture; (2) a symptomatic or rapidly expanding aneurysm, regardless of its size; (3) aneurysms larger than 4 cm in diameter; (4) complicated aneurysms with embolism, thrombosis, or symptomatic occlusive disease; and (5) atypical aneurysms (eg, dissecting, mycotic, saccular). These guidelines must be weighed against the existing clinical risk factors in each patient. With the advent of endoluminal repair, patients who are poor surgical candidates have a possible alternative to open repair. Careful screening of these patients is critical for good outcomes.^{3, 15, 16, 17, 18, 19}

Endovascular repair, such as stent-graft placement, is evolving as an alternative to conventional, open surgical repair (see Image 6). The US Food and Drug Administration has approved several devices for use in the endovascular repair of aneurysms. Each device has benefits and limitations.^{2, 20, 21, 22}

The primary factors that determine suitability for endovascular repair are the diameter and length of the proximal neck of the aneurysm, the tortuosity of the aorta, and the anatomy of the iliac arteries.

Endovascular devices rely on radial force (and, for some devices, hooks) to engage the more normal segments of the aorta and iliac arteries and to exclude blood flow from the aneurysmal sac. If the proximal neck is too wide or too short or densely calcified, a good seal cannot be achieved at the attachment site. The sac remains pressurized, and the aneurysm is still at risk of rupture, with endotension or an endoleak.

The flexibility of an endovascular graft is an important consideration in selecting a patient for endovascular repair. If the angle between the neck of the aneurysm and the aorta is too great, the graft may be displaced from its intended position, with a subsequent leak at the attachment site. The leak can occur acutely (type I) or later, as aneurysm shrinkage and remodeling occurs.

The tortuosity of one or both of the iliac arteries can also preclude endovascular repair. If the common iliac arteries are too large, the limb of the stent is not well opposed to the wall of the artery, and a leak at the attachment site results. Embolization of a hypogastric artery can be performed to allow extension of a graft limb to a nonaneurysmal external iliac artery if needed. If the iliac arteries are too small or too tortuous, advancing the stent-graft deployment system into position may be impossible.

The presence of circumferential calcification at the neck is increasingly recognized as a negative prognostic indicator for primary seal formation, and it may indicate an increased risk of rupture during the procedure. Extensive intraluminal thrombus may similarly affect the ability to obtain a secure, long-term seal at the proximal part of the neck.

Concomitant embolization of one or, rarely, both internal iliac arteries may be required prior to graft placement if the iliac arteries are aneurysmal to or beyond the distal common iliac artery. Embolization can lead to buttock claudication and, in rare cases, colonic ischemia or infarction.

Medical/Legal Pitfalls

• Clinicians order radiologic studies during the course of patient examinations. The clinical history should be considered when reviewing the radiologic studies, though it may be misleading in some cases. When abdominal aortic aneurysm (AAA) is suspected, it is rarely missed.
• When an examination, especially a plain radiograph, is ordered for a reason other than the evaluation of AAA, curvilinear calcifications should be carefully assessed because most AAAs are asymptomatic. When they are discovered, the referring clinicians should be notified of the abnormal and unexpected findings. In some cases, a referring clinician might be reminded of the need for appropriate follow-up and the time interval.
• At minimum, radiologists should follow several guidelines to ensure good patient care:
• • The ordering physician should be notified, and US or CT should be recommended, when findings suggestive of AAA are seen on plain radiographs.
  • Recommend appropriate surveillance for aneurysms both before and after their repair.
  • Notify the ordering physician when evidence of arterial wall complications is present. Such evidence includes expansion over time, compression or erosion into adjacent structures, rupture, dissection, and thrombosis.

FURTHER READING

Section 10 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Screening for abdominal aortic aneurysms: recommendation statement.
United States Preventive Services Task Force.  1996 (revised 2005).  16 pages.  NGC:003960
 
Aortic aneurysm and dissection.
Finnish Medical Society Duodecim.  2004 Feb 26.  Various pagings.  [NGC Update Pending] NGC:004359
 
Acute chest pain - suspected aortic dissection.
American College of Radiology.  1995 (revised 2005).  5 pages.  NGC:004621

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

Media file 1:  Radiograph shows calcification of the abdominal aorta. The left wall is clearly depicted and appears aneurysmal; however, the right wall overlies the spine.
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Media file 2:  The lateral view clearly shows calcification of both walls. Abdominal aortic aneurysm can be diagnosed with certainty.
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Media type:  X-RAY

Media file 3:  CT demonstrates an abdominal aortic aneurysm. The aneurysm was noted during workup for back pain, and CT was ordered after the abdominal aortic aneurysm was identified on radiographs. No evidence of rupture is seen (same patient as in Image 2).
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Media type:  CT

Media file 4:  Arteriogram demonstrates an infrarenal abdominal aortic aneurysm. This arteriogram was obtained in preparation of an endovascular repair of the aneurysm (same patient as in Image 2).
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Media type:  X-RAY

Media file 5:  Lateral arteriogram demonstrates an infrarenal abdominal aortic aneurysm. Demonstration of the superior mesenteric artery, inferior mesenteric artery, and celiac artery on the lateral arteriogram in important to completely evaluate the extent of the aneurysm.
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Media type:  X-RAY

Media file 6:  Arteriogram after successful endovascular repair of an abdominal aortic aneurysm.
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Media type:  X-RAY

Media file 7:  Ultrasonogram of a patient with an abdominal aortic aneurysm. This aneurysm was best visualized on a transverse or axial image. This patient underwent a conventional abdominal aortic aneurysm repair.
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Media type:  X-RAY

Media file 8:  MRI of a 77-year-old man with leg pain believed to be secondary to degenerative disk disease. During evaluation, an abdominal aortic aneurysm was discovered.
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Media type:  MRI

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Angiography
• Intervention
• Further Reading
• Multimedia
• References

1. Upchurch GR Jr, Schaub TA. Abdominal aortic aneurysm. Am Fam Physician. Apr 1 2006;73(7):1198-204. [Medline].
2. Tan JW, Yeo KK, Laird JR. Food and Drug Administration-approved endovascular repair devices for abdominal aortic aneurysms: a review. J Vasc Interv Radiol. Jun 2008;19(6 Suppl):S9-S17. [Medline].
3. Lovegrove RE, Javid M, Magee TR, Galland RB. A meta-analysis of 21,178 patients undergoing open or endovascular repair of abdominal aortic aneurysm. Br J Surg. Jun 2008;95(6):677-84. [Medline].
4. Lederle FA, Kane RL, MacDonald R, Wilt TJ. Systematic review: repair of unruptured abdominal aortic aneurysm. Ann Intern Med. May 15 2007;146(10):735-41. [Medline].
5. Pearce WH, Shively VP. Abdominal aortic aneurysm as a complex multifactorial disease: interactions of polymorphisms of inflammatory genes, features of autoimmunity, and current status of MMPs. Ann N Y Acad Sci. Nov 2006;1085:117-32. [Medline].
6. Hirose H, Takagi M, Miyagawa N. Genetic risk factor for abdominal aortic aneurysm: HLA-DR2(15), a Japanese study. J Vasc Surg. Mar 1998;27(3):500-3. [Medline].
7. Golledge J, Muller J, Daugherty A, Norman P. Abdominal aortic aneurysm: pathogenesis and implications for management. Arterioscler Thromb Vasc Biol. Dec 2006;26(12):2605-13. [Medline].
8. Rasmussen TE, Hallett JW Jr. Inflammatory aortic aneurysms. A clinical review with new perspectives in pathogenesis. Ann Surg. Feb 1997;225(2):155-64. [Medline].
9. Salo JA, Soisalon-Soininen S, Bondestam S. Familial occurrence of abdominal aortic aneurysm. Ann Intern Med. Apr 20 1999;130(8):637-42. [Medline].
10. Craig SR, Wilson RG, Walker AJ. Abdominal aortic aneurysm: still missing the message. Br J Surg. Apr 1993;80(4):450-2. [Medline].
11. Alexander S, Bosch JL, Hendriks JM, Visser JJ, Van Sambeek MR. The 30-day mortality of ruptured abdominal aortic aneurysms: influence of gender, age, diameter and comorbidities. J Cardiovasc Surg (Torino). Oct 2008;49(5):633-7. [Medline].
12. Harthun NL. Current issues in the treatment of women with abdominal aortic aneurysm. Gend Med. Mar 2008;5(1):36-43. [Medline].
13. Blanchard JF. Epidemiology of abdominal aortic aneurysms. Epidemiol Rev. 1999;21(2):207-21. [Medline].
14. Rehm JP, Grange JJ, Baxter BT. The formation of aneurysms. Semin Vasc Surg. Sep 1998;11(3):193-202. [Medline].
15. Ahn SS, Rutherford RB, Johnston KW. Reporting standards for infrarenal endovascular abdominal aortic aneurysm repair. Ad Hoc Committee for Standardized Reporting Practices in Vascular Surgery of The Society for Vascular Surgery/International Society for Cardiovascular Surgery. J Vasc Surg. Feb 1997;25(2):405-10. [Medline].
16. Hollier LH, Taylor LM, Ochsner J. Recommended indications for operative treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. J Vasc Surg. Jun 1992;15(6):1046-56. [Medline].
17. Johnston KW, Rutherford RB, Tilson MD. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovasc. J Vasc Surg. Mar 1991;13(3):452-8. [Medline].
18. Grollman J, Bettmann MA, Boxt LM. Pulsatile abdominal mass. American College of Radiology. ACR Appropriateness Criteria. Radiology. Jun 2000;215 Suppl:55-9. [Medline].
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Article Last Updated: Oct 2, 2008