Abdominal aortic aneurysm rupture
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Updates to Article Attributes
RupturedRupture of an abdominal aortic anerurysm is a feared complication of abdominal aortic aneurysm and is a surgical emergency. This article mainly covers an acute abdominal aneurysmal rupture.
Epidemiology
Abdominal aortic aneurysms are common and affect ~7.5% of patients aged over 65 years 6.
Clinical presentation
The classical triad of pain, hypotension and pulsatile abdominal mass due to rupture into the retroperitoneum is only seen in 25-50% of patients.
A chronic rupture may escape detection for about weeks to months and are hence known as sealed aneurysmal rupture or spontaneously healed aneurysmal rupture or abdominal aortic aneurysmal leak.
Unusual presentations of ruptured abdominal aortic aneurysm can carry a mortality rateare
- transient lower limb paralysis
- right hypochondrial pain
- groin pain
- testicular pain
-
testicular ecchymosis (blue scrotum sign of
around 90%1.Bryant) - iliofemoral venous thrombosis
Pathology
The aneurysmal rupture is thought to occur when the mechanical stress is in excess of the wall strength. Thus the aortic aneurysmal wall tension and the aneurysmal diameter are a significant predictor of impending rupture.
The commonest sites of rupture and their relative incidences are
- intraperitoneal rupture: 20%
- retroperitonealrupture: 80%
- aortocaval fistula: 3-4%
- primary aortoenteric fistula: <1%
- aorta left renal vein fistula: very rare; < 30 cases reported
Clinical presentation
The classical triad of pain due to rupture into the retroperitoneal cavity is
painhypotensionpulsatile abdominal mass
A chronic rupture may escape detection for about weeks to months and are hence known as sealed aneurysmal rupture or spontaneously healed aneurysmal rupture or abdominal aortic aneuysmal leak.
Unusual presentations of ruptured abdominal aortic aneurysm are
transientlower limb paralysisright hypochondrial paingroin paintesticular paintesticular ecchymosis(blue scrotum sign of Bryant)iliofemoral venous thrombosis
Radiographic features
Plain film - abdominal radiograph
Not a sensisitivesensitive mode of detection. A calcified aortic aneurysm may be seen with secondary blurring of the psoas outline in case of retroperitoneal haemmorrhage.
Ultrasound
- focal dilatation of the aorta (aneurysm)
- peri-aortic fluid
- free intraperitoneal fluid
- retroperitoneal fluid
- represnting: representing retroperitoneal haemorrhage
CT
Retroperitoneal haemorrhage adjacent the anerusym is the most common finding. The periaortic blood may be seen to extent into perirenal, or pararenal spaces, or the psoas muscles. Intraperitoneal extension of the haemmorrhage may be seen as an immediate or a delayed finding.
An important feature seen in contained rupture of aortic aneurysm is the draped aorta sign - in which the posterior wall of aorta is not seen distinctly from adjacent structures and the contour of the aorta follows that of adjacent vertebrae.
CT angiography
Aneurysm can be well demonstrated. Most often, active extravasation of contrast material can be seen. A hyperattenuating crescent sign which is an area of enhnacement may be seen within the aortic aneurysmal mural thrombus - this represents an intramural haematoma.
Findings predictive of impending rupture
- increased aneurysm size on serial imaging (rate of 10 mm or more per year)
- very large abdominal aortic aneurysm >7cm
- reduced thrombus size
- discontinuity in calcification
- hyperattenuating crescent sign
- well defined peripheral crescent of increased attenuation within the thrombus of a large abdominal aortic aneruysm
ManagementTreatment and prognosis
Treatment in a acute rupture should be prompt an can be with endovascular repair or open surgery. The mortality rate is very high being >90% 6.
-<p><strong>Ruptured abdominal aortic anerurysm</strong> is a feared complication of <a href="/articles/abdominal_aortic_aneurysm">abdominal aortic aneurysm</a> and is a surgical emergency. This article mainly covers an acute abdominal aneurysmal rupture.</p><h4>Epidemiology</h4><p>A ruptured aneurysm can carry a mortality rate of around 90% <sup>1</sup>.</p><h4>Pathology</h4><p>The aneurysmal rupture is thought to occur when the mechanical stress is in excess of the wall strength. Thus the aortic aneurysmal wall tension and the aneurysmal diameter are a significant predictor of impending rupture. </p><p>The commonest sites of rupture and their relative incidences are</p><ul>- +<p><strong>Rupture of an abdominal aortic anerurysm</strong> is a feared complication of <a href="/articles/abdominal-aortic-aneurysm">abdominal aortic aneurysm</a> and is a surgical emergency. This article mainly covers acute abdominal aneurysmal rupture.</p><h4>Epidemiology</h4><p>Abdominal aortic aneurysms are common and affect ~7.5% of patients aged over 65 years <sup>6</sup>.</p><h4>Clinical presentation</h4><p>The classical triad of pain, hypotension and pulsatile abdominal mass due to rupture into the retroperitoneum is only seen in 25-50% of patients. </p><p>A chronic rupture may escape detection for about weeks to months and are hence known as <a href="/articles/sealed-aneurysmal-rupture">sealed aneurysmal rupture</a> or <a href="/articles/spontaneously-healed-aneurysmal-rupture">spontaneously healed aneurysmal rupture</a> or abdominal aortic aneurysmal leak. </p><p>Unusual presentations of ruptured abdominal aortic aneurysm are</p><ul>
- +<li>transient lower limb paralysis</li>
- +<li>right hypochondrial pain</li>
- +<li>groin pain</li>
- +<li>testicular pain</li>
- +<li>testicular ecchymosis (blue scrotum sign of Bryant)</li>
- +<li>iliofemoral venous thrombosis</li>
- +</ul><h4>Pathology</h4><p>The aneurysmal rupture is thought to occur when the mechanical stress is in excess of the wall strength. Thus the aortic aneurysmal wall tension and the aneurysmal diameter are a significant predictor of impending rupture. </p><p>The commonest sites of rupture and their relative incidences are</p><ul>
-</ul><h4>Clinical presentation</h4><p>The classical triad of pain due to rupture into the retroperitoneal cavity is </p><ul>-<li>pain</li>-<li>hypotension</li>-<li>pulsatile abdominal mass</li>-</ul><p>A chronic rupture may escape detection for about weeks to months and are hence known as <strong><a href="/articles/sealed-aneurysmal-rupture">sealed aneurysmal </a><a href="/articles/sealed-aneurysmal-rupture">rupture</a></strong> or <strong><a href="/articles/spontaneously-healed-aneurysmal-rupture">spontaneously healed aneurysmal rupture</a></strong> or <strong>abdominal aortic aneuysmal leak</strong>. </p><p>Unusual presentations of ruptured abdominal aortic aneurysm are</p><ul>-<li>transientlower limb paralysis</li>-<li>right hypochondrial pain</li>-<li>groin pain</li>-<li>testicular pain</li>-<li>testicular ecchymosis(blue scrotum sign of Bryant)</li>-<li>iliofemoral venous thrombosis</li>-</ul><h4>Radiographic features</h4><h5>Plain film - abdominal radiograph</h5><p>Not a sensisitive mode of detection. A calcified aortic aneurysm may be seen with secondary blurring of the psoas outline in case of retroperitoneal haemmorrhage.</p><h5>Ultrasound</h5><ul>- +</ul><h4>Radiographic features</h4><h5>Plain film - abdominal radiograph</h5><p>Not a sensitive mode of detection. A calcified aortic aneurysm may be seen with secondary blurring of the psoas outline in case of retroperitoneal haemmorrhage.</p><h5>Ultrasound</h5><ul>
-<li>retroperitoneal fluid - represnting <a href="/articles/retroperitoneal-haemorrhage">retroperitoneal haemorrhage</a>- +<li>retroperitoneal fluid: representing <a href="/articles/retroperitoneal-haemorrhage">retroperitoneal haemorrhage</a>
-</ul><h5>CT</h5><p><a href="/articles/retroperitoneal-haemorrhage">Retroperitoneal haemorrhage</a> adjacent the anerusym is the most common finding. The periaortic blood may be seen to extent into perirenal, pararenal spaces or the psoas muscles. Intraperitoneal extension of the haemmorrhage may be seen as an immediate or a delayed finding. </p><p>An important feature seen in contained rupture of aortic aneurysm is the <a href="/articles/draped-aorta-sign">draped aorta sign</a> - in which the posterior wall of aorta is not seen distinctly from adjacent structures and the contour of the aorta follows that of adjacent vertebrae. </p><h6>CT angiography</h6><p>Aneurysm can be well demonstrated. Most often, active extravasation of contrast material can be seen. A <a href="/articles/hyperattenuating-crescent-sign">hyperattenuating crescent sign</a> which is an area of enhnacement may be seen within the aortic aneurysmal mural thrombus - this represents an intramural haematoma.</p><h6>Findings predictive of impending rupture</h6><ul>- +</ul><h5>CT</h5><p><a href="/articles/retroperitoneal-haemorrhage">Retroperitoneal haemorrhage</a> adjacent the anerusym is the most common finding. The periaortic blood may be seen to extent into perirenal or pararenal spaces, or the psoas muscles. Intraperitoneal extension of the haemmorrhage may be seen as an immediate or a delayed finding. </p><p>An important feature seen in contained rupture of aortic aneurysm is the <a href="/articles/draped-aorta-sign">draped aorta sign</a> - in which the posterior wall of aorta is not seen distinctly from adjacent structures and the contour of the aorta follows that of adjacent vertebrae. </p><h6>CT angiography</h6><p>Aneurysm can be well demonstrated. Most often, active extravasation of contrast material can be seen. A <a href="/articles/hyperattenuating-crescent-sign">hyperattenuating crescent sign</a> which is an area of enhnacement may be seen within the aortic aneurysmal mural thrombus - this represents an intramural haematoma.</p><h6>Findings predictive of impending rupture</h6><ul>
-</ul><h4>Management</h4><p>Treatment in a acute rupture should be prompt an can be with endovascular repair or open surgery.</p>- +</ul><h4>Treatment and prognosis</h4><p>Treatment in a acute rupture should be prompt an can be with endovascular repair or open surgery. The mortality rate is very high being >90% <sup>6</sup>. </p>
References changed:
- 6. Assar A & Zarins C. Ruptured Abdominal Aortic Aneurysm: A Surgical Emergency with Many Clinical Presentations. Postgrad Med J. 2009;85(1003):268-273. <a href="https://doi.org/10.1136/pgmj.2008.074666">doi:10.1136/pgmj.2008.074666</a>
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