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Abdominal Aorta
T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Procedure

      • Outcomes

        TERMINOLOGY

        • Definitions

          • Abdominal aortic aneurysm (AAA): Localized aortic dilatation; exceeds normal diameter by > 50%
            • ~ 90% occur infrarenally
              • May be fusiform or saccular
              • May or may not involve iliac arteries
            • Considered multifactorial degenerative process
              • Proteolytic degradation of tunica media
                • Basic pathophysiology of AAA development
              • Significant association with atherosclerosis
              • Genetic influence; high familial prevalence
            • Inflammatory aneurysms occur in up to 10%
              • Aortic wall thickening; periadventitial fibrosis
                • May be symptomatic with fever/pain
                • May be immune-mediated process
                • Immunoglobulin G4-related disease reportedly among various causes of inflammatory AAA
            • Infectious (mycotic) AAA occur in 2%
              • Usually due to local bacterial seeding of diseased aortic wall or seeding via vasa vasorum
                • Staphylococcus aureus/Salmonella common
              • Known for rapid growth/rupture/high mortality
            • Heritable disorders (rare)
              • Whole-genome approaches being used to elucidate genetic basis of AAA and uncover genetic variants influencing disease risk
                • Marfan syndrome
                • Ehlers-Danlos syndrome type IV
          • Acute aortic syndromes: Spectrum of abnormalities that acutely compromise aortic wall integrity
            • Abdominal aortic dissection: Intimal tear extends into aortic wall; blood flows between wall layers
              • Usually originates in thoracic aorta; may extend into or may originate in abdominal aorta
                • Tear typically extends antegrade; retrograde extension may also occur
              • Blood flow separates aortic wall structures, producing "true" and "false" lumens
                • Aortic branch vessel perfusion may be compromised; end-organ ischemia may result
              • Weakened aortic wall may rupture; high mortality
                • Chronic dissection may progress to aneurysm
            • Intramural hematoma
              • May occur as primary event in hypertensive patients
                • Spontaneous bleeding from vasa vasorum into aortic media causing hematoma formation
              • May result from penetrating atherosclerotic ulcer
              • Intramural hematoma weakens aortic wall
                • May progress to aortic dissection
                • Increased risk of aortic rupture
            • Penetrating atherosclerotic aortic ulcer: Plaque rupture through aortic internal elastic membrane
              • Subsequent intramural hematoma may occur
              • Ulcer/hematoma weakens aortic wall
                • May progress to aortic dissection
                • May form saccular pseudoaneurysm
                • Increased risk of acute rupture
            • Symptomatic aortic aneurysm
              • Acute onset of severe/continuous/worsening middle abdominal &/or back pain
                • Worrisome for impending AAA rupture
              • Ruptured AAA
          • Abdominal aortic stenotic/occlusive disease
            • Atherosclerosis: Most common cause
              • Severe atherosclerotic stenosis may progress to chronic thrombotic occlusion
                • Acute aortic occlusion more often embolic
              • Leriche syndrome: Distal aorta/iliac occlusion
                • Absent femoral pulses, claudication, impotence
              • "Coral reef" plaque: Bulky, intraluminal, calcified plaque; may almost occlude aortic lumen
                • Frequently occurs in visceral aortic segment; may obstruct visceral/renal arteries
                • Distal embolization from bulky plaque common
              • Ulcerated aortic atherosclerotic plaque may be source of emboli to lower extremities
                • Emboli composed of cholesterol/thrombus/fibrin-platelet aggregates
              • Cholesterol embolization syndrome involves more diffuse cholesterol crystal embolization
                • Acute life-threatening event: Systemic emboli involving brain/eyes/kidneys/extremities
                • Complication of angiography, major vascular surgery, or thrombolytic therapy
                • Microembolization to lower extremities may cause "blue toe" syndrome
            • Coarctation disorders
              • Neurofibromatosis: Often involves vasculature
                • Aortic/branch stenoses (pararenal distribution)
                • Neurofibromatous proliferation in vessel wall
              • William syndrome: Rare congenital disorder
                • Aortic stenosis/developmental delay/elfin facies
              • Middle aortic syndrome: Unclear etiology
                • Narrowed mid-aorta/major visceral branches
                • Occurs in first 2 decades of life
            • Inflammatory etiology
              • Takayasu aortitis: Chronic progressive inflammatory disease affecting aorta/major branches/pulmonary arteries
                • Genetic/autoimmune components
                • Underlying chronic arterial inflammation
                • Extensive periarterial fibrosis/thickening
                • Noncompliant/rigid arterial walls
              • Other immune disorders affecting aorta
                • Behçet disease, polyarteritis nodosa (rare)
              • Infectious
                • Usually aneurysmal instead of occlusive disease
          • Traumatic aortic injury
            • Penetrating: Involves abdominal > thoracic aorta
            • Blunt: Motor vehicle/crush injuries common
              • Seat belt deceleration injury can cause trauma to infrarenal abdominal aorta
              • Primary aortic lesions include rupture, intimal disruption/transection and pseudoaneurysm
            • High mortality rate

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      OUTCOMES

                      • Complications

                        • Expected Outcomes

                          Selected References

                          1. Uğuz E et al: Treatment of acute thoracic aortic syndromes using endovascular techniques. Diagn Interv Radiol. 22(4):365-70, 2016
                          2. Valente T et al: MDCT evaluation of acute aortic syndrome (AAS). Br J Radiol. 89(1061):20150825, 2016
                          3. Wolfschmidt F et al: Aortic dissection: Accurate subintimal flap fenestration by using a reentry catheter with fluoroscopic guidance-initial single-institution experience. Radiology. 276(3):862-72, 2015
                          4. Sadaghianloo N et al: Blunt abdominal aortic trauma in paediatric patients. Injury. 45(1):183-91, 2014
                          5. Araújo PV et al: Endovascular treatment for acute aortic syndrome. Ann Vasc Surg. 26(4):516-20, 2012
                          6. Gilani R et al: Endovascular therapy for overcoming challenges presented with blunt abdominal aortic injury. Vasc Endovascular Surg. 46(4):329-31, 2012
                          7. Nathan DP et al: Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg. 55(1):10-5, 2012
                          8. Dangas GD et al: Endovascular treatment of infrarenal aortic stenosis: importance of multimodality imaging. J Invasive Cardiol. 23(8):E192-6, 2011
                          9. Lew WK et al: Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas. Ann Vasc Surg. 23(1):81-9, 2009
                          10. Delis KT et al: Middle aortic syndrome: from presentation to contemporary open surgical and endovascular treatment. Perspect Vasc Surg Endovasc Ther. 17(3):187-203, 2005
                          11. Liang P et al: Advances in the medical and surgical treatment of Takayasu arteritis. Curr Opin Rheumatol. 17(1):16-24, 2005
                          12. Min PK et al: Endovascular therapy combined with immunosuppressive treatment for occlusive arterial disease in patients with Takayasu's arteritis. J Endovasc Ther. 12(1):28-34, 2005
                          13. Hines GL et al: Infrarenal aortic rupture secondary to neurofibromatosis. Ann Vasc Surg. 16(6):784-6, 2002
                          14. Cormier JM et al: [Arterial complications of neurofibromatosis.] J Mal Vasc. 24(4):281-6, 1999
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Terminology

                            • Procedure

                              • Outcomes

                                TERMINOLOGY

                                • Definitions

                                  • Abdominal aortic aneurysm (AAA): Localized aortic dilatation; exceeds normal diameter by > 50%
                                    • ~ 90% occur infrarenally
                                      • May be fusiform or saccular
                                      • May or may not involve iliac arteries
                                    • Considered multifactorial degenerative process
                                      • Proteolytic degradation of tunica media
                                        • Basic pathophysiology of AAA development
                                      • Significant association with atherosclerosis
                                      • Genetic influence; high familial prevalence
                                    • Inflammatory aneurysms occur in up to 10%
                                      • Aortic wall thickening; periadventitial fibrosis
                                        • May be symptomatic with fever/pain
                                        • May be immune-mediated process
                                        • Immunoglobulin G4-related disease reportedly among various causes of inflammatory AAA
                                    • Infectious (mycotic) AAA occur in 2%
                                      • Usually due to local bacterial seeding of diseased aortic wall or seeding via vasa vasorum
                                        • Staphylococcus aureus/Salmonella common
                                      • Known for rapid growth/rupture/high mortality
                                    • Heritable disorders (rare)
                                      • Whole-genome approaches being used to elucidate genetic basis of AAA and uncover genetic variants influencing disease risk
                                        • Marfan syndrome
                                        • Ehlers-Danlos syndrome type IV
                                  • Acute aortic syndromes: Spectrum of abnormalities that acutely compromise aortic wall integrity
                                    • Abdominal aortic dissection: Intimal tear extends into aortic wall; blood flows between wall layers
                                      • Usually originates in thoracic aorta; may extend into or may originate in abdominal aorta
                                        • Tear typically extends antegrade; retrograde extension may also occur
                                      • Blood flow separates aortic wall structures, producing "true" and "false" lumens
                                        • Aortic branch vessel perfusion may be compromised; end-organ ischemia may result
                                      • Weakened aortic wall may rupture; high mortality
                                        • Chronic dissection may progress to aneurysm
                                    • Intramural hematoma
                                      • May occur as primary event in hypertensive patients
                                        • Spontaneous bleeding from vasa vasorum into aortic media causing hematoma formation
                                      • May result from penetrating atherosclerotic ulcer
                                      • Intramural hematoma weakens aortic wall
                                        • May progress to aortic dissection
                                        • Increased risk of aortic rupture
                                    • Penetrating atherosclerotic aortic ulcer: Plaque rupture through aortic internal elastic membrane
                                      • Subsequent intramural hematoma may occur
                                      • Ulcer/hematoma weakens aortic wall
                                        • May progress to aortic dissection
                                        • May form saccular pseudoaneurysm
                                        • Increased risk of acute rupture
                                    • Symptomatic aortic aneurysm
                                      • Acute onset of severe/continuous/worsening middle abdominal &/or back pain
                                        • Worrisome for impending AAA rupture
                                      • Ruptured AAA
                                  • Abdominal aortic stenotic/occlusive disease
                                    • Atherosclerosis: Most common cause
                                      • Severe atherosclerotic stenosis may progress to chronic thrombotic occlusion
                                        • Acute aortic occlusion more often embolic
                                      • Leriche syndrome: Distal aorta/iliac occlusion
                                        • Absent femoral pulses, claudication, impotence
                                      • "Coral reef" plaque: Bulky, intraluminal, calcified plaque; may almost occlude aortic lumen
                                        • Frequently occurs in visceral aortic segment; may obstruct visceral/renal arteries
                                        • Distal embolization from bulky plaque common
                                      • Ulcerated aortic atherosclerotic plaque may be source of emboli to lower extremities
                                        • Emboli composed of cholesterol/thrombus/fibrin-platelet aggregates
                                      • Cholesterol embolization syndrome involves more diffuse cholesterol crystal embolization
                                        • Acute life-threatening event: Systemic emboli involving brain/eyes/kidneys/extremities
                                        • Complication of angiography, major vascular surgery, or thrombolytic therapy
                                        • Microembolization to lower extremities may cause "blue toe" syndrome
                                    • Coarctation disorders
                                      • Neurofibromatosis: Often involves vasculature
                                        • Aortic/branch stenoses (pararenal distribution)
                                        • Neurofibromatous proliferation in vessel wall
                                      • William syndrome: Rare congenital disorder
                                        • Aortic stenosis/developmental delay/elfin facies
                                      • Middle aortic syndrome: Unclear etiology
                                        • Narrowed mid-aorta/major visceral branches
                                        • Occurs in first 2 decades of life
                                    • Inflammatory etiology
                                      • Takayasu aortitis: Chronic progressive inflammatory disease affecting aorta/major branches/pulmonary arteries
                                        • Genetic/autoimmune components
                                        • Underlying chronic arterial inflammation
                                        • Extensive periarterial fibrosis/thickening
                                        • Noncompliant/rigid arterial walls
                                      • Other immune disorders affecting aorta
                                        • Behçet disease, polyarteritis nodosa (rare)
                                      • Infectious
                                        • Usually aneurysmal instead of occlusive disease
                                  • Traumatic aortic injury
                                    • Penetrating: Involves abdominal > thoracic aorta
                                    • Blunt: Motor vehicle/crush injuries common
                                      • Seat belt deceleration injury can cause trauma to infrarenal abdominal aorta
                                      • Primary aortic lesions include rupture, intimal disruption/transection and pseudoaneurysm
                                    • High mortality rate

                                PREPROCEDURE

                                • Indications

                                  • Contraindications

                                    • Preprocedure Imaging

                                      • Getting Started

                                        PROCEDURE

                                        • Patient Position/Location

                                          • Procedure Steps

                                            • Alternative Procedures/Therapies

                                              OUTCOMES

                                              • Complications

                                                • Expected Outcomes

                                                  Selected References

                                                  1. Uğuz E et al: Treatment of acute thoracic aortic syndromes using endovascular techniques. Diagn Interv Radiol. 22(4):365-70, 2016
                                                  2. Valente T et al: MDCT evaluation of acute aortic syndrome (AAS). Br J Radiol. 89(1061):20150825, 2016
                                                  3. Wolfschmidt F et al: Aortic dissection: Accurate subintimal flap fenestration by using a reentry catheter with fluoroscopic guidance-initial single-institution experience. Radiology. 276(3):862-72, 2015
                                                  4. Sadaghianloo N et al: Blunt abdominal aortic trauma in paediatric patients. Injury. 45(1):183-91, 2014
                                                  5. Araújo PV et al: Endovascular treatment for acute aortic syndrome. Ann Vasc Surg. 26(4):516-20, 2012
                                                  6. Gilani R et al: Endovascular therapy for overcoming challenges presented with blunt abdominal aortic injury. Vasc Endovascular Surg. 46(4):329-31, 2012
                                                  7. Nathan DP et al: Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg. 55(1):10-5, 2012
                                                  8. Dangas GD et al: Endovascular treatment of infrarenal aortic stenosis: importance of multimodality imaging. J Invasive Cardiol. 23(8):E192-6, 2011
                                                  9. Lew WK et al: Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas. Ann Vasc Surg. 23(1):81-9, 2009
                                                  10. Delis KT et al: Middle aortic syndrome: from presentation to contemporary open surgical and endovascular treatment. Perspect Vasc Surg Endovasc Ther. 17(3):187-203, 2005
                                                  11. Liang P et al: Advances in the medical and surgical treatment of Takayasu arteritis. Curr Opin Rheumatol. 17(1):16-24, 2005
                                                  12. Min PK et al: Endovascular therapy combined with immunosuppressive treatment for occlusive arterial disease in patients with Takayasu's arteritis. J Endovasc Ther. 12(1):28-34, 2005
                                                  13. Hines GL et al: Infrarenal aortic rupture secondary to neurofibromatosis. Ann Vasc Surg. 16(6):784-6, 2002
                                                  14. Cormier JM et al: [Arterial complications of neurofibromatosis.] J Mal Vasc. 24(4):281-6, 1999