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Bedside Ultrasonography Evaluation of Abdominal Aortic Aneurysm

  • Author: Timothy Jang, MD; Chief Editor: Caroline R Taylor, MD  more...
 
Updated: Sep 20, 2015
 

Overview

Background

Ultrasonography for the detection of abdominal aortic aneurysm (AAA) has been shown to be sensitive, specific, and relatively simple to perform.[1, 2, 3, 4] A 1998 study by Plummer et al demonstrated its utility as a point-of-care test in the emergency department (ED) by showing faster time to diagnosis and higher rate of survival of ruptured AAA.[5] Further validation studies have shown that emergency medicine (EM) residents and, by extension, appropriately trained EM physicians, are able to quickly and accurately identify AAA using ultrasound at the bedside.[6]

It is important to remember, however, that while bedside ultrasonography can be especially useful in an unstable patient who cannot leave the ED or other acute care patient setting for computed tomography (CT) of the abdomen, it should never delay potentially lifesaving abdominal surgery when such surgery is immediately available and the diagnosis is strongly suspected.[7]

A leaking or ruptured AAA classically presents in patients who are older than 60 years who have a history of hypertension and atherosclerosis and who experience severe abdominal, back, or flank pain after an episode of syncope.[8] Although AAA is more common in men than in women, the incidence of rupture is greater in women because the growth rate of AAA is significantly greater in women than in men.[9]

Unfortunately, less than 50% of patients with ruptured AAA present with the classic triad of syncope followed by back, flank, or abdominal pain and a pulsatile abdominal mass.[10] Up to 30-60% of patients with AAA are initially misdiagnosed.[11, 12, 13, 14] Be careful not to confuse AAA with more benign diagnoses such as renal colic, mechanical back pain, or diverticulitis. Maintain a high index of suspicion in patients older than 60 years who present with pain in the abdomen, back, flank, or groin.

Additionally, in at-risk patients who may present with an unrelated chief complaint, emergency ultrasonography can be a fast and accurate method for identifying patients with AAA who may benefit from follow-up or intervention.[15] The main disadvantages in bedside ultrasonography are that a leaking or ruptured aneurysm can be difficult to distinguish from an enlarged but nonruptured aneurysm. The aorta can also be difficult to visualize when the patient is obese or bowel gas is present.[16]

The abdominal aorta is said to have an aneurysm when the distal aorta is dilated to a diameter larger than 3 cm.[17] An AAA typically enlarges at a rate of 2-8 mm/y. Because enlargement results in an increasing incidence of rupture[18] (eg, a 7-cm AAA has a 19-32% rate of rupture per year) and because the mortality rate is much lower with elective repair than with emergency repair (3-5% vs 50%), the general recommendation is that AAAs larger than 5.0-5.5 cm should be electively repaired.[17, 19]

Go to Abdominal Aortic Aneurysm and Emergent Management of Impending Rupture/Rupture of Abdominal Aortic Aneurysm for complete information on these topics.

Indications

Indications for bedside ultrasonography include the following:

  • Suspicion of AAA
  • As a diagnostic aid in the evaluation of patients older than 60 years who present with nonspecific pain in the back, flank, abdomen, or groin
  • For rapid evaluation of an unstable patient in the ED or other acute care patient setting while the surgical team is assembling and resuscitation is ongoing

The U.S. Preventive Services Task Force (USPSTF) recommends the following[20, 21] :

  • One-time screening for AAA with ultrasonography in men aged 65-75 years who have ever smoked.
  • Selective screening for AAA in men aged 65-75 years who have never smoked.
  • Current evidence is insufficient to assess the balance of benefits and harms of screening for AAA in women aged 65-75 years who have ever smoked.
  • Recommendation against routine screening for AAA in women who have never smoked.

Contraindications

Abdominal ultrasonography should not be performed if it would delay definitive care by means of abdominal surgery.

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Preparation

Anesthesia

Anesthesia is generally not necessary for sonographic evaluation, because the procedure is not usually painful. The patient should be warned, however, that a considerable amount of pressure is sometimes necessary to obtain quality images. This pressure may be unanticipated and mildly uncomfortable.

Equipment

Equipment includes the following:

  • Ultrasonograph with an abdominal transducer (the standard probe used for this examination is a 3.5- to 5-MHz transducer)
  • Gloves
  • Acoustic gel for application on the patient’s upper abdomen, the transducer, or both

Positioning

The procedure should be done with the patient in the supine recumbent position.

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Technique

Overview

Although abdominal ultrasonography in the emergency department (ED) or other acute care patient setting is a good test for suspected abdominal aortic aneurysm (AAA), do not delay operative care to obtain images in an unstable patient.

Explain the procedure, benefits, risks, and complications to the patient and/or the patient’s representative. Ask if he or she would like others to be present for the procedure.

Disrobe the abdomen from xiphoid to pubis. Apply a generous amount of acoustic gel to the patient’s upper abdomen (from xiphoid to umbilicus), the transducer, or both.

Scan the upper abdomen in the transverse plane while holding the probe perpendicular to the patient’s long axis. Identify the aorta and trace it to its bifurcation with the iliac vessels (see the image and the videos below).

A demonstration of ultrasonographic aortic evaluation. Video courtesy of Meghan Kelly Herbst, MD, and Department of Emergency Medicine, Yale School of Medicine.
Probe starts in transverse plane at level of proximal aorta, where "seagull sign" (bifurcation of celiac trunk) can be appreciated. Probe is then rocked caudally, whereby 3.5-cm abdominal aortic aneurysm is revealed.

The abdominal aorta can be distinguished from the vena cava (see the image below) by its thicker wall, pulsations, noncompressible nature, and ability to detect pulsatile Doppler flow.

Transverse view of vertebral body, inferior vena c Transverse view of vertebral body, inferior vena cava (IVC), portal vein, and aorta (clockwise from bottom middle).

Acquire pictures in the transverse plane, and use the external diameter (outer wall to outer wall) to measure the diameter of the aorta at its widest point (see the image and the video below). An accurate measurement of the aorta’s size is important because the risk of rupture is related to the overall size of the aorta.

Transverse view of 7-cm abdominal aortic aneurysm. Transverse view of 7-cm abdominal aortic aneurysm.
Transverse view of 7-cm abdominal aortic aneurysm with echogenic mural thrombus.

Scan the upper abdomen in the longitudinal plane, holding the probe parallel to the long axis of the patient’s body. Acquire pictures in the longitudinal plane, and measure the diameter at the widest point (see the images and the video below). Remember that a diameter larger than 3 cm is considered to represent abnormal dilatation.

Scanning upper abdomen in longitudinal plane to vi Scanning upper abdomen in longitudinal plane to visualize abdominal aorta.
Longitudinal view of abdominal aorta (black stripe Longitudinal view of abdominal aorta (black stripe in middle of image).
Using Doppler mode to confirm that visualized stru Using Doppler mode to confirm that visualized structure is aorta (see pulsatile waveforms).
Aorta is visualized first in short axis and then in long axis. Large (>7 cm) abdominal aortic aneurysm with mural thrombus and hypoechoic areas is appreciated outside aorta, which may represent rupture. Color-flow Doppler illustrates turbulent flow within lumen.

Once images have been acquired in both transverse and longitudinal planes and the aorta’s diameter has been measured, emergency bedside ultrasonographic imaging for AAA is complete. Wipe the gel from the patient and transducer, cover the patient, and place him or her in a position of comfort.

Visualizing an enlarged (>3 cm) abdominal aorta is diagnostic of AAA, though rupture cannot be definitively diagnosed with ultrasonography alone. The first two videos below depict AAA, while the third depicts normal aortic anatomy.

Color cine loop depicting abdominal aortic aneurysm (AAA). Video courtesy of Meghan Kelly Herbst, MD, and Department of Emergency Medicine, Yale School of Medicine.
Cine loop of abdominal aortic aneurysm (AAA). Video courtesy of Meghan Kelly Herbst, MD, and Department of Emergency Medicine, Yale School of Medicine.
Cine loop depicting normal aorta anatomy. Video courtesy of Meghan Kelly Herbst, MD, and Department of Emergency Medicine, Yale School of Medicine.

In the appropriate clinical context, ultrasonography alone can rule in the diagnosis of rupture when rupture appears to be present. However, if adequate images cannot be obtained (eg, because of patient obesity or bowel gas), the diagnosis of aortic rupture cannot be excluded.

Common pitfalls in performing bedside ultrasonography to evaluate AAA include the following:

  • Failing to compress the overlying bowel adequately with probe pressure
  • Mistaking the vena cava for the aorta because of transmitted pulsations
  • Overestimating the aneurysmal width because of the lack of a true transverse measurement (cross-section)
  • Confusing an imaging artifact with thrombus
  • Failing to measure the external diameter (outer wall to outer wall)
  • Failing to move the transducer off the sagittal plane while following a tortuous aorta
  • Misinterpreting acoustic enhancement distal to the aorta as evidence of leakage. (Remember that ultrasonography is not good at detecting rupture or leakage. Contrast abdominal computed tomography [CT] is the criterion standard. However, contrast-enhanced ultrasonography may be a reasonable alternative to CT, if CT is unavailable. [22] )
  • Being reluctant to move the transducer far laterally in an attempt to visualize an aorta that is obscured by overlying bowel gas
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Post-Procedure

Complications

Bedside ultrasonography for evaluation of abdominal aortic aneurysm (AAA) has no major complications, aside from the potential complications that could ensue if immediately available surgical repair is delayed for the purpose of obtaining imaging studies.

Although no data suggest that palpation of an AAA by physical examination or with the probe increases the rate of rupture or worsens an already rupturing AAA, repeated examinations for teaching purposes are not advised.

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Contributor Information and Disclosures
Author

Timothy Jang, MD Associate Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director of Emergency Ultrasonography, Department of Emergency Medicine, Harbor-UCLA Medical Center

Timothy Jang, MD is a member of the following medical societies: American College of Emergency Physicians, American Institute of Ultrasound in Medicine, Christian Medical and Dental Associations, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Eleanor Oakley, MD Fellow in Emergency Ultrasound, Department of Emergency Medicine, Harbor-UCLA Medical Center

Eleanor Oakley, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Caroline R Taylor, MD Associate Professor, Department of Diagnostic Radiology, Yale University School of Medicine; Chief, Diagnostic Imaging Service, Veterans Affairs Connecticut Health Care System

Caroline R Taylor, MD is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Thomas J Hemingway, MD Attending Physician, Department of Emergency Medicine, Wilcox Memorial Hospital

Thomas J Hemingway, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Edward T Tham, MD Fellow in Emergency Ultrasound, Clinical Instructor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgments

Medscape Reference thanks Meghan Kelly Herbst, MD, Emergency Ultrasound Director, Department of Emergency Medicine, Hartford Hospital, for assistance with the video contribution to this article. Medscape Reference also thanks Yale School of Medicine, Emergency Medicine for assistance with the video contribution to this article.

References
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  2. Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Acad Emerg Med. 2003 Aug. 10(8):867-71. [Medline].

  3. Mastracci TM, Cinà CS. Screening for abdominal aortic aneurysm in Canada: review and position statement of the Canadian Society for Vascular Surgery. J Vasc Surg. 2007 Jun. 45(6):1268-1276. [Medline].

  4. Dent B, Kendall RJ, Boyle AA, Atkinson PR. Emergency ultrasound of the abdominal aorta by UK emergency physicians: a prospective cohort study. Emerg Med J. 2007 Aug. 24(8):547-9. [Medline]. [Full Text].

  5. Plummer D, Clinton J, Matthew B. Emergency department ultrasound improves time to diagnosis and survival in ruptured abdominal aortic aneurysm. Academic Emergency medicine. 1998. 5:417.

  6. Costantino TG, Bruno EC, Handly N. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. Ann Emerg Med. April 2007. 49(4):547.

  7. Ruff AL, Teng K, Hu B, Rothberg MB. Screening for abdominal aortic aneurysms in outpatient primary care clinics. Am J Med. 2015 Mar. 128 (3):283-8. [Medline].

  8. Zankl AR, Schumacher H, Krumsdorf U, Katus HA, Jahn L, Tiefenbacher CP. Pathology, natural history and treatment of abdominal aortic aneurysms. Clin Res Cardiol. 2007 Mar. 96(3):140-51. [Medline].

  9. Bhatt S, Dogra VS. Catastrophes of abdominal aorta: sonographic evaluation. Ultrasound Clin. January 2008. 3(1):83-91.

  10. Heller M, Dietrich J. Ultrasound in Emergency Medicine. Philadelphia, Pa: WB Saunders; 1995. 86-95.

  11. Marston WA, Ahlquist R, Johnson G Jr, Meyer AA. Misdiagnosis of ruptured abdominal aortic aneurysms. J Vasc Surg. 1992 Jul. 16(1):17-22. [Medline].

  12. Akkersdijk GJ, van Bockel JH. Ruptured abdominal aortic aneurysm: initial misdiagnosis and the effect on treatment. Eur J Surg. 1998 Jan. 164(1):29-34. [Medline].

  13. Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med. 2000 Oct. 36(4):406-15. [Medline].

  14. Lederle FA, Parenti CM, Chute EP. Ruptured abdominal aortic aneurysm: the internist as diagnostician. Am J Med. 1994 Feb. 96(2):163-7. [Medline].

  15. Moore CL, Holliday RS, Hwang JQ, Osborne MR. Screening for abdominal aortic aneurysm in asymptomatic at-risk patients using emergency ultrasound. Am J Emerg Med. October 2008. 26(8):883-87.

  16. Sparks AR, Johnson PL, Meyer MC. Imaging of abdominal aortic aneurysms. Am Fam Physician. 2002 Apr 15. 65(8):1565-70. [Medline].

  17. Tan WA, Makaroun MS. Aortic Aneurysm, Rupture. http://emedicine.medscape.com/article/416397-overview. Medscape Reference [serial online]. March 23, 2007. Available at http://emedicine.medscape.com/. Accessed: July 21, 2008.

  18. Lederle FA, Johnson GR, Wilson SE, Ballard DJ, Jordan WD Jr, Blebea J, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002 Jun 12. 287(22):2968-72. [Medline].

  19. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007 Apr 18. CD002945. [Medline].

  20. LeFevre ML, U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Aug 19. 161 (4):281-90. [Medline].

  21. Campos-Outcalt D. Catching up on the latest USPSTF recommendations. J Fam Pract. 2015 May. 64 (5):296-300. [Medline].

  22. Iezzi R, Basilico R, Giancristofaro D, Pascali D, Cotroneo AR, Storto ML. Contrast-enhanced ultrasound versus color duplex ultrasound imaging in the follow-up of patients after endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2009 Mar. 49(3):552-60. [Medline].

 
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Scanning of upper abdomen from xiphoid to umbilicus in transverse plane to follow abdominal aorta to its iliac bifurcation.
Transverse view of vertebral body, inferior vena cava (IVC), portal vein, and aorta (clockwise from bottom middle).
Transverse view of 7-cm abdominal aortic aneurysm.
Scanning upper abdomen in longitudinal plane to visualize abdominal aorta.
Longitudinal view of abdominal aorta (black stripe in middle of image).
Using Doppler mode to confirm that visualized structure is aorta (see pulsatile waveforms).
Probe starts in transverse plane at level of proximal aorta, where "seagull sign" (bifurcation of celiac trunk) can be appreciated. Probe is then rocked caudally, whereby 3.5-cm abdominal aortic aneurysm is revealed.
Aorta is visualized first in short axis and then in long axis. Large (>7 cm) abdominal aortic aneurysm with mural thrombus and hypoechoic areas is appreciated outside aorta, which may represent rupture. Color-flow Doppler illustrates turbulent flow within lumen.
Transverse view of 7-cm abdominal aortic aneurysm with echogenic mural thrombus.
A demonstration of ultrasonographic aortic evaluation. Video courtesy of Meghan Kelly Herbst, MD, and Department of Emergency Medicine, Yale School of Medicine.
Color cine loop depicting abdominal aortic aneurysm (AAA). Video courtesy of Meghan Kelly Herbst, MD, and Department of Emergency Medicine, Yale School of Medicine.
Cine loop of abdominal aortic aneurysm (AAA). Video courtesy of Meghan Kelly Herbst, MD, and Department of Emergency Medicine, Yale School of Medicine.
Cine loop depicting normal aorta anatomy. Video courtesy of Meghan Kelly Herbst, MD, and Department of Emergency Medicine, Yale School of Medicine.
Probe starts in transverse plane at level of proximal aorta, where "seagull sign" (bifurcation of celiac trunk) can be appreciated. Probe is then rocked caudally, whereby 3.5-cm abdominal aortic aneurysm is revealed.
 
 
 
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