eMedicine Specialties > Radiology > Vascular/Interventional

Abdominal Aortic Aneurysm, Diagnosis: Follow-up

Author: Martin G Radvany, MD, FSIR, Adjunct Assistant Professor, Departments of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences; Interventional Neuroradiology Fellow, Johns Hopkins Hospital
Coauthor(s): Venerando Seguritan, MD, Staff Radiologist, Radiology, The Radiology Group, Inc.
Contributor Information and Disclosures

Updated: Oct 2, 2008

Intervention


Arteriogram after successful endovascular repair ...

Arteriogram after successful endovascular repair of an abdominal aortic aneurysm.

[ CLOSE WINDOW ]
Arteriogram after successful endovascular repair ...

Arteriogram after successful endovascular repair of an abdominal aortic aneurysm.


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 above and Image 6 in Multimedia). 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.

Medicolegal 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.
 


More on Abdominal Aortic Aneurysm, Diagnosis

Overview: Abdominal Aortic Aneurysm, Diagnosis
Imaging: Abdominal Aortic Aneurysm, Diagnosis
Follow-up: Abdominal Aortic Aneurysm, Diagnosis
Multimedia: Abdominal Aortic Aneurysm, Diagnosis
References
Further Reading
[ CLOSE WINDOW ]

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. [Best Evidence] 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].

  19. Rentschler ME, Baxter BT. Medical therapy approach for treating abdominal aortic aneurysm. Vascular. Nov-Dec 2007;15(6):361-5. [Medline].

  20. Rayt HS, Sutton AJ, London NJ, Sayers RD, Bown MJ. A Systematic Review and Meta-analysis of Endovascular Repair (EVAR) for Ruptured Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg. Sep 16 2008;[Medline].

  21. Muszbek N, Thompson MM, Soong CV, Hutton J, Brasseur P, van Sambeek MR. Systematic review of utilities in abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. Sep 2008;36(3):283-9. [Medline].

  22. Wilt TJ, Lederle FA, Macdonald R, Jonk YC, Rector TS, Kane RL. Comparison of endovascular and open surgical repairs for abdominal aortic aneurysm. Evid Rep Technol Assess (Full Rep). Aug 2006;1-113. [Medline].

[ CLOSE WINDOW ]

Further Reading

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

[ CLOSE WINDOW ]

Keywords

abdominal aortic aneurysm, inflammatory aortic aneurysm, aortic aneurysm, AAAs, triple-A, triple A, abdominal aneurysm, noninflammatory aneurysms, inflammatory aneurysms, abdominal aortic dissection, aneurysm, dissection

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Martin G Radvany, MD, FSIR, Adjunct Assistant Professor, Departments of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences; Interventional Neuroradiology Fellow, Johns Hopkins Hospital
Martin G Radvany, MD, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, International Society of Endovascular Specialists, Radiological Society of North America, Society of Interventional Radiology, Society of NeuroInterventional Surgery, and Western Angiographic and Interventional Society
Disclosure: Nothing to disclose.

Coauthor(s)

Venerando Seguritan, MD, Staff Radiologist, Radiology, The Radiology Group, Inc.
Venerando Seguritan, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Eric P Weinberg, MD, Associate Professor, Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital
Eric P Weinberg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Spencer B Gay, MD, Professor of Radiology, Director of Body Computed Tomography, Department of Radiology, University of Virginia Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Kyung J Cho, MD, FACR, William Martel Professor of Radiology, Interventional Radiology Fellowship Director, University of Michigan Health System
Kyung J Cho, MD, FACR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.