Abdominal aortic aneurysms that have ruptured or are at imminent risk of rupture.

The rupture of an abdominal aortic aneurysm (AAA) is considered a high-risk surgical emergency, given the catastrophic consequences and high mortality rate. The objective of this pictorial essay is to illustrate the radiological signs that indicate rupture or imminent rupture. To that end, we describe cases treated at our facility and present a brief review of the literature on the topic. The clinical diagnosis of imminent AAA rupture can be difficult, because patients are usually asymptomatic or have nonspecific pain complaints. In the subsequent follow-up, it is possible to identify radiological signs that indicate instability or rupture itself and thus change the prognosis. Computed tomography is the modality of choice for evaluating an AAA and abdominal pain in the emergency setting. It is therefore essential that the radiologist immediately identify the imaging findings that indicate AAA rupture or the imminent risk of such rupture.

A ruptura de aneurisma da aorta abdominal (AAA) é considerada uma emergência cirúrgica de altíssimo risco, pelas consequências catastróficas e pelo alto índice de mortalidade. Este ensaio iconográfico tem como objetivo ilustrar os sinais radiológicos que indiquem ruptura ou a sua iminência. Utilizamos casos atendidos no nosso serviço e apresentamos breve revisão bibliográfica acerca do tema. O diagnóstico clínico da iminência de ruptura de AAA pode ser difícil, visto que os pacientes são normalmente assintomáticos ou apresentam queixas álgicas inespecíficas. No controle evolutivo, podem ser identificados sinais radiológicos que indiquem instabilidade ou a própria ruptura e, dessa forma, mudar o prognóstico do paciente. Como a tomografia computadorizada é a modalidade de escolha para a avaliação dos AAAs e da dor abdominal no cenário da emergência, torna-se imprescindível o reconhecimento precoce pelo radiologista dos achados de imagem que indiquem aneurismas rotos ou com risco iminente de ruptura.

Abdominal aortic aneurysms that have ruptured or are at imminent risk of rupture / Aneurismas de aorta abdominal rotos e com risco iminente de ruptura

Abstract The rupture of an abdominal aortic aneurysm (AAA) is considered a high-risk surgical emergency, given the catastrophic consequences and high mortality rate. The objective of this pictorial essay is to illustrate the radiological signs that indicate rupture or imminent rupture. To that end, we describe cases treated at our facility and present a brief review of the literature on the topic. The clinical diagnosis of imminent AAA rupture can be difficult, because patients are usually asymptomatic or have nonspecific pain complaints. In the subsequent follow-up, it is possible to identify radiological signs that indicate instability or rupture itself and thus change the prognosis. Computed tomography is the modality of choice for evaluating an AAA and abdominal pain in the emergency setting. It is therefore essential that the radiologist immediately identify the imaging findings that indicate AAA rupture or the imminent risk of such rupture.

Resumo A ruptura de aneurisma da aorta abdominal (AAA) é considerada uma emergência cirúrgica de altíssimo risco, pelas consequências catastróficas e pelo alto índice de mortalidade. Este ensaio iconográfico tem como objetivo ilustrar os sinais radiológicos que indiquem ruptura ou a sua iminência. Utilizamos casos atendidos no nosso serviço e apresentamos breve revisão bibliográfica acerca do tema. O diagnóstico clínico da iminência de ruptura de AAA pode ser difícil, visto que os pacientes são normalmente assintomáticos ou apresentam queixas álgicas inespecíficas. No controle evolutivo, podem ser identificados sinais radiológicos que indiquem instabilidade ou a própria ruptura e, dessa forma, mudar o prognóstico do paciente. Como a tomografia computadorizada é a modalidade de escolha para a avaliação dos AAAs e da dor abdominal no cenário da emergência, torna-se imprescindível o reconhecimento precoce pelo radiologista dos achados de imagem que indiquem aneurismas rotos ou com risco iminente de ruptura.

Surgical Repair of a 13-cm Infrarenal Abdominal Aortic Aneurysm with Aortocaval Fistula in a 63-Year-Old Tuba Player.

Infrarenal abdominal aortic aneurysm with aortocaval fistula, a rare condition, can be fatal without prompt intervention. The clinical symptoms are complex and varied, so diagnosis is typically confirmed by use of contrast-enhanced multidetector computed tomography. We report our surgical repair of a 13-cm-diameter infrarenal abdominal aortic aneurysm and aortocaval fistula in a 63-year-old orchestral tuba player who had 2 classic symptoms of the condition. The unruptured aneurysm and fistula were complicated by acutely angled vessels, so we performed surgery rather than endovascular repair. The patient recovered fully and was discharged from the hospital. This infrarenal aneurysm with aortocaval fistula is perhaps the largest to have been treated successfully by means of open surgery. In addition to our patient's case, we discuss the history and treatment considerations of this rare combined condition.

Endovascular Abdominal Aortic Aneurysm Repair by Means of the Chimney Technique in a Patient with Crossed Fused Renal Ectopia.

Crossed fused renal ectopia, a congenital anomaly in 1 of 7,000 individuals, presents a challenge during endovascular treatment of abdominal aortic aneurysm. Most treatment approaches in these patients have involved open surgical repair of the aneurysm or endovascular repair with coverage of the ectopic renal artery. We present what we think is the first case of endovascular abdominal aortic aneurysm repair with use of the chimney technique (parallel stent-grafting) to preserve an ectopic renal artery, in an 88-year-old man who was at high risk for open surgery. In addition to the patient's case, we discuss the relevant medical literature.

Long-term results of aortic banding for complex infrarenal neck anatomy and type I endoleak after endovascular abdominal aortic aneurysm repair.

For many patients with abdominal aortic aneurysm, unsuitable anatomy of the infrarenal aortic neck precludes endovascular aortic aneurysm repair or causes type I endoleak after the procedure. In an attempt to overcome these challenges, we retrospectively examined the usefulness of aortic banding as an adjunctive procedure to endovascular repair in 8 patients who had an abdominal aortic aneurysm with a complex infrarenal aortic neck. The procedures were performed with the patients under general anesthesia and involved making an 8-cm upper-midline laparotomy incision to expose the aneurysmal aorta. Three patients underwent aortic banding before endovascular repair; the other 5 underwent banding after the repair because of persistent type I endoleak. After banding, the abdominal aortic aneurysm was successfully excluded in all 8 patients. Long-term follow-up (mean, 38±20 mo) revealed no type I endoleak and no procedure-related complications. In patients who have an abdominal aortic aneurysm with complex infrarenal neck anatomy or a refractory type I endoleak, performing aortic banding as an adjunctive procedure to endovascular aortic repair appears to be a safe strategy with good long-term results.

Use of the IntuiTrak stent-graft delivery system for percutaneous abdominal aortic aneurysm exclusion: initial single-center experience.

The exclusion of abdominal aortic aneurysms by endovascular techniques has enabled the treatment of patients who have high-risk comorbidities that preclude safe surgical repair. Since the development of the unibody bifurcated endovascular stent-graft for abdominal aortic aneurysm exclusion, remarkable technological improvements have facilitated stent-graft delivery and reduced the required size of the access site. Our initial institutional experience with the use of the Endologix IntuiTrak Express Delivery System for the Powerlink stent-graft (in 7 patients) shows that the device is suited for percutaneous use without sequelae. Herein, we describe the IntuiTrak system and the successful results of its use: we achieved percutaneous access and closure in all 7 patients, with no conversions to open repair or vascular exposure.