Clinical Features and Diagnosis of Abdominal Aortic Aneurysm - UpToDate

8/1/2017
ClinicalfeaturesanddiagnosisofabdominalaorticaneurysmUpToDate
OfficialreprintfromUpToDate
www.uptodate.com2017UpToDate
Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm
Authors: JeffreyJim,MD,RobertWThompson,MD
SectionEditors: JosephLMills,Sr,MD,JohnFEidt,MD,EmileRMohlerIII,MD
DeputyEditor: KathrynACollins,MD,PhD,FACS
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Dec2016.|Thistopiclastupdated:Jun28,2016.
INTRODUCTIONAbdominalaorticaneurysm(AAA),whichisanabnormalfocaldilationoftheabdominalaorta,is
relativelycommonandhasthepotentialforsignificantmorbidityandmortality.MostpatientswithAAAare
asymptomaticbutcometomedicalattentionbyfindingofapulsatilemassonphysicalexamination,astheresultof
otherabdominalimagingstudies,orthroughultrasoundscreeningprogramsforAAA[1].Whensymptomsdooccur,
patientscommonlypresentwithabdominal,back,orflankpain,butthromboembolismcanalsooccurleadingto
symptomsoflimbischemia.Aneurysmsthatproducesymptomsareatanincreasedriskforrupture,whichis
associatedwithhighmortalityrates.
AdiagnosisofAAAgenerallyrequiresimagingconfirmationthatananeurysmispresent,whichismostoften
accomplishedusingabdominalultrasound.However,insymptomaticpatients,computedtomographyofthe
abdomenprovidesadditionalinformationthatcandetermineiftheaneurysmhasruptured,isexpandingrapidly,and
forthosewithoutsignsofrupture,whetherornotsymptomsarelikelytoberelatedtotheaneurysmorduetoother
abdominalpathology.
TheclinicalfeaturesanddiagnosisofAAAwillbereviewedhere.Themanagementofnonrupturedandruptured
AAAarediscussedelsewhere.(See"Managementofasymptomaticabdominalaorticaneurysm",sectionon
'Introduction'and"Managementofsymptomatic(nonruptured)andrupturedabdominalaorticaneurysm",section
on'Introduction'.)
ANEURYSMDEFINITIONANDANATOMYAnaneurysmisdefinedasasegmental,fullthicknessdilationofa
bloodvessel50percentgreaterthanitsnormaldiameter[2,3].Althoughnormaldiametervarieswithage,gender,
andbodyhabitus,theaveragediameterofthehumaninfrarenalaortaisabout2.0cmtheupperlimitofnormalis
typically<3.0cm[4].Thus,forthemajorityofpatients,aninfrarenalaortawithamaximumdiameter3.0cmis
aneurysmal[2,4,5].Thenormaldiameterofthesuprarenalaortatendstobeabout0.5cmlargerthantheinfrarenal
aorta.
Theaortadilateswithageandthenormalaorticdiameterinolderpatientstendstobelarger.Inapopulationbased
studyusingmagneticresonanceimagingtoobtainaorticdiametersatvariouslevelsin70yearoldpatients,the
averagediameterswere[6]:
AbovetheceliacarteryMen:3.0cm,Women:2.7cm
AbovetherenalarteriesMen:2.8cm,Women:2.7cm
JustbelowtherenalarteriesMen:2.4cm,Women:2.2cm
AtaorticbifurcationMen:2.3cm,Women:2.0cm
Theabdominalaorta(figure1)isthemostcommonanatomicsiteofarterialaneurysm[3].Abdominalaortic
aneurysms(AAAs)aredescribedrelativetotheinvolvementoftherenalorvisceralvessels.
InfrarenalTheaneurysmoriginatesbelowtherenalarteries(image1andimage2).
JuxtarenalTheaneurysmoriginatesattheleveloftherenalarteriesbuttheaortaattherenalarteriesis
normal.
PararenalTheaneurysminvolvestheaortaattheleveloftherenalarteries,ie,therenalarteryoriginates
fromananeurysmalaorta(image3).
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Suprarenal(visceral)Theaneurysmoriginatesabovetherenalarteries.
MostAAAsareinfrarenal(figure2).About15percentarejuxtarenal[7].Suprarenalaneurysmsnotalsoaffecting
theinfrarenal,juxtarenal,orthoracicaortaareuncommon,butmaydeveloplatefollowingAAArepair[8].
RISKFACTORSRiskfactorsassociatedwithAAAarelistedhereandarediscussedindetailelsewhere.(See
"Epidemiology,riskfactors,pathogenesisandnaturalhistoryofabdominalaorticaneurysm".)
ThefollowingareassociatedwithanincreasedriskofdevelopingAAA[3,912]:
Smoking
Malegender
Advancingage
Caucasianrace
Atherosclerosis
FamilyhistoryofAAA
Otherperipheralarteryaneurysm(iliac,femoral,popliteal)
Connectivetissuedisorder(eg,Marfan,EhlersDanlos,LoeysDietzsyndromes)orfamilyhistory
Priorhistoryofaorticdissection
Priorhistoryofaorticsurgeryorinstrumentation
Theriskofaneurysmruptureisincreasedwith:
Largeinitialaneurysmdiameter(>5.5cm)
Currentsmoking
Elevatedbloodpressure
Greateraorticexpansionrate(>0.5cm/year)
Femalegender
Symptoms
NonCaucasianraceanddiabetesareassociatedwithadecreasedriskforAAA[11].Althoughasmallerpercentage
ofwomenhaveaneurysms(approximately20percentofallAAAdiagnoses),womenpresentwithrupturemore
oftenthanmen[13].
CLINICALPRESENTATIONSAbdominalaorticaneurysmpresentsclinicallyinavarietyofways.Mostindividuals
withAAAhavenosymptoms.Whensymptomsdooccur,painisthemostcommoncomplaint.Painmayormaynot
beassociatedwithAAAruptureorotherassociatedsymptoms.
AsymptomaticAAAAnasymptomatic(occult)AAAmaybediscoveredasaresultofscreening,onroutine
physicalexamination,oronimagingstudiesobtainedtoevaluateanunrelatedcondition.
ScreeningforAAAScreeningforAAAisperformedindefinedpopulationsbaseduponrisk.Insome,butnot
allcountries,screeningprogramsforAAAappeartohavecontributedtoareducedincidenceofrupturedAAA
[1,14,15].ScreeningforAAAisdiscussedelsewhere.(See"Screeningforabdominalaorticaneurysm".)
PulsatileabdominalmassApproximately30percentofasymptomaticAAAsmaybesuspectedwhena
pulsatileabdominalmassispalpatedonroutinephysicalexamination[16].Theabilitytopalpateandestimate
theaorticdiameterdependsuponthepatientsbodyhabitus,thesizeoftheaneurysm,andtheclinical
experienceofthepractitioner.(See'Abdominalpalpation'below.)
IncidentalfindingonradiographyAAAisfrequentlydetectedasanincidentalfindingonimagingstudies
performedforotherpurposes[1720].Itisimportanttonotethatthisinformationisoftennotpassedontothe
referringphysician,anduptoonethirdofpatientswithaneurysmsdetectedincidentallyunderwentno
subsequentmonitoring[17,2123].Thefollowingfindingsareillustrative:[23]
OnereviewstudyidentifiedAAAin1percentof79,121abdominalimagingstudiesincludingcomputed
tomographyoftheabdomen,ultrasound,andmagneticresonanceimaging[17].Themeanaorticdiameter
was4.0cm.ThepresenceofAAAwascommunicatedtothefamilyphysicianinonly15percentofpatients.
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Anotherreviewidentifieddelayedrecognitionordelayedcommunicationofincidentalfindingsoncomputed
tomographyinnearlytwothirdsofpatients,includingeightpatientswhohadAAA>5.5cm,which
represented9percentofnewlydiagnosedaorticdilations[21].
AssociatedarterialdiseaseAAAmayalsobedetectedduringtheclinicalexaminationorworkupforlower
extremitysymptoms(eg,claudication)thoughttobeduetoperipheralarterydisease,orevaluationrelatedto
anotherperipheralaneurysm(iliac,femoral,popliteal)(image4).Iliacaneurysmcommonlyoccursinassociation
withAAA.Inaretrospectivereviewof10,038patientswithiliacaneurysm,89percenthadacoexistentAAA
[24].Anotherstudyfounda14percentincidenceoffemoraland/orpoplitealarteryaneurysmsinassociation
withAAA[25].(See"Poplitealarteryaneurysm"and"Iliacarteryaneurysm".)
Symptomatic(nonruptured)AAASymptomaticAAAreferstoanyofanumberofsymptomsthatcanbe
attributedtotheaneurysm.Insurgicalseries,between5and22percentofAAAaresymptomatic[2631].Because
symptomsinassociationwithadiagnosisofAAAincreasetheriskforrupture,symptomsthatarenotobviously
attributabletoanothercause(eg,diverticulitis),shouldbepresumedtobeduetotheaneurysm,untilproven
otherwise.(See'Symptoms'belowand"Managementofasymptomaticabdominalaorticaneurysm",sectionon
'Aneurysmrepairversusconservativemanagement'.)
AAAcanalsopresentinitiallyasacomplicationofinstrumentationoftheaorta(eg,arteriography,cardiac
catheterization).Ascathetersarepassedthroughtheaorta,thrombusoratheroscleroticdebrisassociatedwiththe
aneurysmcandislodgeandembolizedistally.ThromboembolismfromthrombuswithinAAAhasalsobeenreported
followingabdominaltrauma[32].(See'Limbischemia'below.)
RupturedAAAAorticruptureisduetotheweakeningoftheaorticwalltotheextentthatitcannolongersupport
theforcesimposeduponitleadingtoafullthicknesstissuelossthatresultsinescapeofbloodoutsidetheconfines
oftheaorta.WhetheraorticruptureisduetoAAAortoanotherdiseaseprocess(eg,penetratingaorticulcer,aortic
dissection)canonlybeascertainedthoughaorticimaging.
TheincidenceofrupturedAAAinhospitalizedpatientsunderestimatestheoverallincidenceofrupturedAAA
becauseonlyabouthalfofpatientswithrupturedabdominalaorticaneurysmsurvivelongenoughfortreatment,and
notallpatientswithsuddendeathundergoautopsytoconfirmthecauseofdeath.(See"Epidemiology,riskfactors,
pathogenesisandnaturalhistoryofabdominalaorticaneurysm".)
AAAcanpresentinitiallywithrupturewithnointerveningsymptoms.AlthoughthesignsandsymptomsofrAAAmay
beobvious(eg,patientwithknownAAAinshock),somepresentationsmakerupturedAAAdifficultto
recognize.Patientswithruptureintotheretroperitoneummayattributetheirsymptomstoothercauses,anddelay
seekingmedicalattention.Evenafterpresentingtoaphysician,amisdiagnosisofrAAAasureteralcolic,myocardial
infarction,perforatedviscus,diverticulitis,gastrointestinalhemorrhage,orischemicboweloccursabout30percentof
thetime[33,34].Asystematicreviewnotedthat,althoughadvancedcrosssectionalimaginghasbecomemore
widelyavailable,therateofinitialmisdiagnosisforpatientswithrAAAdecreasedonlyslightlyfrom42percentfor
studiesperformedbefore1990to32percentforthoseperformedlater(fourstudies)[33].
AnunsuspectedAAArupturecanalsobediagnosedonimagingstudiesobtainedtoevaluatesymptomspresumed
tobeduetoanotherdiagnosis,oradiagnosisofrupturedAAAmayonlybelearneduponautopsyafterthepatients
demise.
TheclinicalpresentationofrupturedAAAinpatientswhohaveundergonepriorendovascularrepairissimilartode
novorupture.PostEVARruptureisduetounresolvedendoleakrepressurizingtheaneurysmsacandismost
commonlyseeninpatientswhohaveundergoneEVARwithlessthanidealanatomyorinthosewhohavenotbeen
compliantwithpostEVARfollowup[35].(See"Complicationsofendovascularabdominalaorticrepair",sectionon
'Endoleak'.)
CLINICALFEATURES
HistoryThemedicalhistoryisusefulfordeterminingthepatientsriskfordevelopingAAA,andifAAAispresent,
thepotentialforrupture.(See'Riskfactors'above.)
Inadditiontoassessingriskfactors,thepatientandhis/herguardianshouldbeasked:
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WhetheradiagnosisofAAAhasbeenestablishedinthepast.Valuesofaorticdiameterfrompriorimaging
studiesshouldbeobtainedforcomparison.Wheneverserialimagingstudiesareavailable,priorratesofaortic
expansion(cm/year)shouldbeobtained(orcalculated)(image5).Thiscanbeaccomplishedbytakingthe
maximalaorticdiameterfromoneyearandsubtractingthediameterfromtheprioryearanddividingbythe
numberofinterveningyears.Asanexample,iftheaneurysmmeasured3.5cmoneyearand5.25cmtwo
yearslater,theexpansionrateis(5.25cm3.5cm)/2yearsor0.875cm/year,whichexceedstheaverage
expansionrateof0.5cm/yearandmayincreasetheriskforrupture.(See'AresymptomsrelatedtoAAA?'
belowand"Epidemiology,riskfactors,pathogenesisandnaturalhistoryofabdominalaorticaneurysm",section
on'ExpansionandruptureofAAA'.)
WhetherpriorAAArepairhasbeenundertaken.Dilationofthesuprarenalabdominalaortacanoccurafter
openorendovascularAAArepair[36],orinthecaseofpriorendovascularrepair,mechanicalproblemscan
leadtoendoleak,whichcanpressurizetheresidualinfrarenalaorticsacandpotentiallyleadtorupture[37].
FollowingopenAAArepair,lateanastomoticfailurescanoccurattheproximalordistalanastomosiswithor
withoutassociatedgraftinfection,leadingtopseudoaneurysm.(See"Complicationsofendovascularabdominal
aorticrepair",sectionon'Endoleak'and"Opensurgicalrepairofabdominalaorticaneurysm",sectionon
'Morbidityandmortality'and'AresymptomsrelatedtoAAA?'below.)
ThepatientmayormaynotbeawareofadiagnosisofAAApriortoclinicalmanifestationsofrupture.Only20to30
percentofpatientswhopresenttoanemergencydepartmentwithrupturehaveaknownhistoryofAAA[38,39].
Inpatientswhopresentwithsymptoms,thehistoryshouldalsoseekknowndiseaseprocessesthatcancause
abdominal/backorflankpain,aswellastoidentifypriorabdominalsurgeries(eg,cholecystectomy,appendectomy).
(See'Differentialdiagnosis'below.)
SymptomsMostindividualswithAAAhavenosymptoms.YoungerpatientswithAAAmaybemorelikelytohave
symptomscomparedwitholderpatients[40].Whensymptomsdooccur,painlocatedintheabdomen,back,orflank
isthemostcommonclinicalmanifestation[3].AAAcanalsopresentwithlimbischemia,orwithsystemic
manifestationsrelatedtoaninfectedaneurysmorinflammatoryaneurysm.Thesesymptomsandotherclinical
manifestationsmayormaynotberelatedtoAAArupture.Theclassictriadofsevereacutepain,apulsatile
abdominalmass,andhypotensionoccursinabout50percentofpatientswithrupturedAAA[33,4143].
SymptomspotentiallyrelatedtoAAAcanmimicmanyotherdiseaseshowever,inpatientsknowntohave,or
subsequentlyshowntohaveAAA,symptomsarepresumedtobeduetotheaneurysmuntilunequivocallyproven
otherwise.(See'Differentialdiagnosis'belowand'AresymptomsrelatedtoAAA?'below.)
PainPatternsofpainreferabletoAAAvarywidelyrelatedtothediameterandpositionoftheaneurysm,
whethertheaneurysmisruptured,andifruptured,thenature(containedorfree)andthelocationoftherupture
(proximalordistalaorta).However,acomplaintofabdominalpainisrelativelynonspecificandcanbeduetoa
varietyofotherconditions.Thegeneralapproachandevaluationofpatientswithabdominalpainisdiscussedin
detailelsewhere.(See"Evaluationoftheadultwithabdominalpain".)
PainrelatedtoAAAistypicallylocatedintheabdomen,butbackorflankpain,pelvicpain,orpainradiatingtothe
groinorthigharealsodescribed[44].Oneretrospectivereviewof66rupturedAAAsreportedpainasapresenting
symptomin75percentofpatients45percenthadabdominalpain,17percenthadflank/backpain,and14percent
hadboth[43].Abdominalpainwasassociatedwithnauseain20percentandsyncopeorafaintfeelinginabout30
percentofpatients.Inasystematicreview,theincidenceofabdominalpainonpresentationwasbetween49and72
percent[33].
Thelocationofthepaincanusuallyberelatedtothepositionoftheaneurysm,withaneurysmspositionedmore
proximallyproducingupperabdominal/backpainanddistalaneurysmsproducinglowerabdominal/pelvicpainor
radiculopathy.Thepainistypicallyunaffectedbypositionormovement.
Physiologically,thepainassociatedwithAAAisrelatedto[44,45]:
Compressionand/orerosionoftheaneurysmintosurroundingstructures(eg,spine),whichtypicallydoesnot
occurunlesstheaneurysmislarge(>5.5cm).
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Rapidexpansionoftheaneurysm(>0.5cm/year),whichcanproducevague,nonspecific,abdominaldiscomfort
ormorefocalpain.
Inflammationorinfectionoftheaorticwall(eg,inflammatoryaneurysm,infectedaneurysm),whichproduces
vague,nonspecificabdominalpainthatmaybeassociatedwithconstitutionalsymptoms(eg,fever,weightloss).
Aneurysmrupture,whichproducessuddenonset,severepain.
AnindolentonsetofpainthatisvagueandnonspecificismoretypicalofnonrupturedAAA.Thetimecoursefrom
theonsetofpaintoseekingmedicalattentionishighlyvariable.
AAArupturetypicallyproducesacute,severeabdominalpainandothermanifestationsthataredeterminedbythe
locationoftherupture,andwhethertheruptureiscontained,rupturesfreelyintotheperitoneum,orrupturesintoan
adjacentvenousstructurecausingafistula(eg,aortocaval,aortoiliac)[44].Autopsystudieshavefoundthat
abdominalaorticaneurysmruptureoccursmostcommonlyintheposterioraorta,whichcorrelatestothelevelsof
higheststressinmechanicalmodelingstudies[4648].
Proximalaorticruptureneartherenalarteriesleadstosevereback/flankpain,whereasdistalrupturenearthe
iliacbifurcationcauseslowabdominal/pelvicpainandmaycausepainthatradiatestothegroinorthighdueto
lumbarnerveirritation.
Posterioraorticwallruptureislikelytobeinitiallycontainedwithintheretroperitoneumleadingtoretroperitoneal
hematoma.Theinitialruptureisassociatedwithasevere,oftenfocalpain.Ifthehematomastabilizes,thepain
maysubside.Patientswithposteriorrupturemayattributetheinitialpaintoanothercause,anddelayseeking
medicalattention.
Ruptureoftheanterioraorticwallmaybecontainedforabriefperiodoftime.Theinitialclinicalmanifestation
willbeabdominalpain,butruptureislikelytoprogressquicklytofreeintraperitonealrupturewithprofound
hemodynamicinstability.Manyofthesepatientssuccumbbeforetheyareabletobetransportedtothehospital.
LimbischemiaAAAcanpresentinitiallywithsymptomsoflowerextremityischemiaduetoembolismof
thrombusoratheroscleroticdebrisfromtheaneurysm[32,49].Inassociationwithabdominal/back/flankpain,distal
embolismcanbeasignofaneurysmrupture.Rarely,AAAcanalsopresentwithacuteaorticthrombosisleadingto
bilaterallowerextremityischemia,orrarely,spinalcordischemia[50,51].
DuringAAAformation,thrombusbuildsupgraduallyalongthewallastheaortaexpandsovertime.Thisthrombusis
typicallylaminated,wellformed,andadherenttothewalloftheaorta,butmaybecomedisruptedasaresultofmore
abruptchangesinaorticwallconfiguration(ie,rapidexpansion),instrumentation,ortrauma[32,49].Insome
patients,aorticdebrismaybemorefriableandmorepronetoembolization.DuringAAArupture,newthrombusmay
formintheregionoftheaortictear,whichcanalsoembolizehowever,distalembolizationassociatedwithAAA
rupturemaymoreoftenberelatedtoaorticmanipulationduringopenrepair,orinstrumentationduringendovascular
repair[49].(See"Complicationsofendovascularabdominalaorticrepair",sectionon'Extremityischemia'.)
DistalembolizationofatherothromboticdebrisfromtheaneurysmasasourceofsymptomsofAAAisnotwell
studied.Intheavailablestudies,uptoonethirdoftheclinicalmanifestationsassociatedwithsymptomaticAAAmay
berelatedtoembolism,buttheincidencevarieswidely[49].ThisvariabilityislikelyduetothefactthatAAAasthe
sourceforlowerextremityischemiaisinferredfromimagingstudiesthataretypicallyobtainedtoevaluate
progressionofchroniclowerextremitysymptoms(eg,claudication,ischemicpain).Inoneretrospectivereviewof
302patientswhounderwentrepairofAAA,15patientspresentedwithdistalembolizationasthefirstmanifestation
oftheirAAA,whichwaslimbthreateningin3patients[49].Inthisstudy,theriskofembolizationdidnotcorrelate
withaneurysmdiameter13of15oftheaneurysmsthatpresentedwithembolizationwere<5.0cm.
ThromboembolifromAAAcanbesingleormultiple.Theclinicalmanifestationsofdistalthromboembolismdepend
uponthesizeofthedebris,andnumberofembolicevents.Clinicalmanifestationsmaynotbeapparentifsmaller
vesselsareaffectedandarterialocclusioniswellcompensated,orthepatientsmaypresentwithchronicsymptoms
(eg,claudication).Alternatively,embolismmaypresentacutelywithpainful,bluedigits(bluetoesyndrome)orwitha
painful,pulseless,coolextremity.Theclinicalmanifestationsofthromboembolicdiseasearediscussedindetail
elsewhere.(See"Embolismfromaorticplaque:Thromboembolism"and"Overviewofacutearterialocclusionofthe
extremities(acutelimbischemia)",sectionon'Clinicalpresentations'.)
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CholesterolembolizationasamanifestationofAAAislesscommon,andmostoftenoccursafterinstrumentation
(eg,arteriography,cardiaccatheterization)oraneurysmrepair(openorendovascular).(See"Embolismfrom
atheroscleroticplaque:Atheroembolism(cholesterolcrystalembolism)",sectionon'Clinicalmanifestations'.)
OthermanifestationsOthermanifestationsofAAAincludeconstitutionalorsystemicsymptomsthatmay
indicatethepresenceofaninfectedorinflammatoryaneurysm,disseminatedintravascularcoagulation,andother
moreunusualmanifestationsofAAArupture.
Symptomsoffever,malaise,andothervagueabdominalsymptoms,whichareoftenchronic,mayindicatea
primaryaorticinfectionwithaneurysmformationorsecondaryinfectionofanestablishedAAA.Theclinical
manifestationsofinfectedaneurysmsarediscussedelsewhere.(See"Overviewofinfected(mycotic)arterial
aneurysm".)
SymptomsofchronicabdominalpainandweightlossinassociationwithAAAaresuggestiveofaninflammatory
aneurysm,whichaffectsabout5to10percentofpatientswithAAA[5255].WhenAAAinitiallypresentsinthis
manner,thediagnosisisfrequentlyconfoundedanddelayed.Patientswiththeinflammatoryvariantareyounger
andmoreoftensymptomaticthanpatientswithnoninflammatoryAAA.PatientswithinflammatoryAAAalso
haveabnormalitiesofseruminflammatorymarkers,suchastheerythrocytesedimentationrate.Ureteral
displacementorsymptomsofureteralobstructioncanalsooccurduetotheretroperitonealinflammatory
reaction(image6).TheincidenceofruptureinpatientswithinflammatoryAAAmaybelowerthanwith
noninflammatoryaneurysm.Inareviewthatincluded180patients,ruptureoccurredin4percentofpatientswith
inflammatoryaneurysmcomparedwith20percentofthosewithnoninflammatoryaneurysms[56].
LargeorextensiveAAAsmaybeassociatedwithclinicalmanifestationsofdisseminatedintravascular
coagulation(DIC)causinghemorrhagicorthromboticcomplications.TheincidenceofDICisreportedtobeas
highas4percent[57,58].(See"Clinicalfeatures,diagnosis,andtreatmentofdisseminatedintravascular
coagulationinadults".)
OtherclinicalmanifestationsthatcanbeassociatedwithrupturedAAAbutarelesscommonlyconsidered
relatedinclude:
Myocardialinfarctionrelatedtoacutebloodloss,whichoccursinupto25percentofpatients[39].
Heartfailureduetoarteriovenousfistulaasaresultofruptureoftheaortaintoasurroundingvenous
structuresuchastheinferiorvenacava(image7),iliacvein,orleftrenalvein.Hematuriaormassiveleg
swellingandlowerextremitycyanosiswithoutdistalischemiacanalsobesignsofaortocavalfistula[59].
(See"Evaluationofthepatientwithsuspectedheartfailure",sectionon'Physicalexamination'.)
Groinpainorthesuddenappearanceofgroinhernia(evenincarceration)canoccurrelatedtoasudden
increaseinintraabdominalpressure[60].
Uppergastrointestinalbleedingmaybeduetoanaortoduodenalfistula(image8)Althoughmore
commonlyrelatedtoaorticgraftrepair,aortoduodenalfistulahasbeenreportedinprimaryinfectedaortic
aneurysm.(See"Aortoentericfistula:Recognitionandmanagement".)
PhysicalexaminationInpatientswithriskfactorsforandsymptomssuggestiveofAAA,thephysical
examinationseekstoidentifyclinicalsignsthatsupportadiagnosisofAAA,orpossiblysuggestanalternative
diagnosis.
Vitalsignsinsymptomaticpatientsmaybenormal,demonstratesinustachycardia,ormoderatetosevere
hypotension.Thedegreeofhypotensioninpatientswithaposterioraorticwallruptureislikelytobelesssevere
uponinitialclinicalpresentationcomparedwithpatientswhosufferfromanterioraorticwallrupture[44].Fever
associatedwithAAAmayindicateaninfectedaneurysm.
AbdominalpalpationThesoleuseofabdominalpalpationcannotbereliedupontodiagnoseorexclude
AAA.AlthoughabdominalexaminationmayreliablydiagnosealargeAAA(>5.5cm),AAAisidentifiedonphysical
examinationaloneinfewerthan50percentofasymptomaticpatients[61].However,inpatientswithrupturedAAA,a
pulsatileabdominalmassispresentinupto62percentofpatients,andisanimportantsignformakingacorrect
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initialdiagnosis[33].MostpatientswithrupturedAAAalsohavesomedegreeofabdominaldistentionand
tenderness.
AnabdominalexaminationfocusedspecificallyonthediagnosisofAAAismorelikelytoidentifyananeurysmthana
nonfocusedexamination.AAAmostoftenoccursinthesegmentofaortabelowtherenalarteries(figure1)[3].
Thus,withthepatientsupineontheexaminationtableandgarmentsremovedfromtheabdomen,palpationofthe
abdominalaortaisperformedbygentlybutdeeplypalpatingtheabdomenbetweenthexiphoidandumbilicus,to
identifyawidenedpulsethatsuggeststhepresenceofananeurysm[62].Manypatientswillexperiencemild
tendernesswithdeeppalpationoftheaneurysm.Patientswithinflammatoryorinfectedaneurysmsmayexhibita
greaterdegreeoftendernesstopalpation.Thisfindingshouldnotbeusedtobrandtheaneurysmassymptomaticin
ordertojustifytreatment.ItisimportanttonotethatpalpationoftheabdomentodetectAAAissafeandhasnever
beenreportedtoprecipitateaorticrupture[62].
DetectionofanAAAbyabdominalpalpationismorelikelywhentheaneurysmislargeandwhenabdominalgirthis
small(waist<40inches).ThesensitivityandspecificityofabdominalpalpationforAAAasrelatedtoAAAdiameter
andgirthareillustratedinthefollowingstudies:
Asystematicreviewevaluated15studiesinvolvingpatientsnotpreviouslyknowntohaveanAAAandwhowere
screenedwithbothabdominalpalpationandultrasound[62].Thesensitivityofabdominalpalpationwas29
percentforAAA3.0to3.9cmindiameter,50percentforAAA4.0to4.9cm,and76percentforAAA5.0cmor
greater.
Inalaterstudyof200patients,theoverallsensitivityofabdominalpalpationfordetectingAAAwas68percent
andthespecificitywas75percent[16].Sensitivitysignificantlyimprovedwithincreasinganeurysmdiameter(61
percent,3.0to3.9cm69percent,4.0to4.9cm72percent,4.0cmorlarger82percent>5.0cm).The
patientsabdominalcircumferencealsoaffectedtheexaminationwithanoverallsensitivityof91percentfor
patientswithawaistline<40inches(100cm)versus53percentfor>40inches(100cm).Forawaistlineof<40
inches,abdominalpalpationwas100percentsensitivefordetectingAAA5.0cm.
Aprominentbutnormalsizedaortaoranonvascularmassoverlyinganeasilytransmitted,palpableaorticpulsecan
bemistakenasAAA,particularlyinthinpatients.Patientswithhypertension,awidepulsepressure,oratortuous
aortacanalsohaveprominentaorticpulsationthatmaybemistakenforanAAA.Forthesereasons,itisimportant
toobtainanimagingstudytoconfirmAAAdiagnosedonthebasisofabdominalpalpation.(See'Diagnosis'below.)
EcchymosisExtensiveretroperitonealhematomafromrupturedAAAmayleadtoextravasationofbloodinto
thesubcutaneoustissuestoproduceflankecchymosis(GreyTurnersign)(image9),periumbilicalecchymosis
(Cullenssign)(picture1),ecchymosisoftheproximalthigh(Foxssign),andinmales,discolorationofthescrotum
(Bryantssign)[63].Althoughthesesignsareindicativeofretroperitonealhematomaandmaysuggestruptured
AAAinpatientswithpositiveriskfactorsforAAAandappropriateclinicalsymptomsandsigns,theyarenotspecific
[63].Otherpathologiesthatmayleadtoecchymosisatthesesitesincludeacutepancreatitis,rupturedectopic
pregnancy,rupturedhepatocellularhematoma,andperinephrichematoma.
VascularexaminationAcompleteperipheralarterialexaminationshouldbeperformedlookingforevidence
ofdistalembolizationorischemia.Theidentificationofotherperipheralarteryaneurysms(femoral,popliteal)on
physicalexaminationsupportsadiagnosisofAAA[25].
Onvascularexamination,thecarotidandradialpulsesshouldbeequalasymmetrysuggestsaorticpathologyinthe
chest(eg,aorticdissection).Femoralandpedalpulsesmayormaynotbepalpabledependinguponthepatients
bloodpressure,thepresenceofperipheralarterydisease,orthromboembolism.Iflowerextremitypulsesarenot
easilyidentified,ahandheldcontinuouswaveDopplercanbeusedtolocatethem.IfpalpableorDopplerablepulses
inthefeetareidentified(dorsalispedis,posteriortibial),itishelpfultomarkthevesselsforlatercomparison.
LaboratorystudiesTherearenolaboratorystudiesthatidentifythepresenceofAAAwithcertainty.Although
hemostaticmarkersmaybeelevatedinpatientswithAAA,thesearenonspecificandcanbeabnormalinavarietyof
otherthromboticconditions,andsomealsoincreasewithage[6468].
AsystematicreviewthatcomparedhemostaticmarkersinpatientswithandwithoutAAAfoundasignificant
associationbetweenAAAandelevatedplasmalevelsoffibrinogen,Ddimer,andthrombinantithrombinIIIcomplex
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[67].Thesemarkersmayreflectdepositionandturnoverofthrombuswithintheaneurysmsac(image10).Ddimer
concentrationisstronglycorrelatedwithaneurysmdiameter(r20.94).SerialDdimerlevelshavebeenusedtofollow
patientswithknownAAA[65,66].ElevatedtotalhomocysteinehasalsobeenassociatedwiththepresenceofAAA
inoldermen[69].SimilartoDdimer,apositivecorrelationbetweenincreasingconcentrationandincreasingaortic
diameterhasbeenidentified.
IntheAtherosclerosisRiskinCommunitiesStudycohort,biomarkersofinflammation,hemostasis,thrombin
generation,cardiacdysfunction,andvascularstiffnessweremeasuredin15,411individuals45to64yearsofageat
riskforAAA[70].Overamedianof22.5years,587AAAswereidentifiedwiththemajorityoccurringinsmokers
comparedwithneversmokers(506versus71).TheoccurrenceofAAAwasdeterminedthroughhospitalization
recordsandforthosepatientsaliveatthefifthandfinalvisit,throughabdominalultrasound.Whitebloodcellcount,
fibrinogen,Ddimer,troponinT,Nterminalprobrainnatriureticpeptide,andhighsensitivityCreactiveprotein[CRP]
wereassociatedwithanincreaseinincidentAAAdiagnosisduringthefollowupperiod.Afteradjustmentforother
riskfactors,thehazardratiosforAAA(smokersandnonsmokers)for1,2,3,or4to6biomarkerscomparedwithno
biomarkerswere2.2,3.3,4.0,and9.9,respectively,inthehighestquartile.CRPwasnotassociatedwithAAAin
neversmokers.Therewerenosignificantdifferencesformencomparedwithwomen.Wedonotobtainsuch
laboratoriesasameanstoscreenordiagnoseAAAhowever,inthefuture,suchbiomarkersmaybecomeusefulfor
followingasymptomaticaneurysm.(See"Managementofasymptomaticabdominalaorticaneurysm",sectionon
'Aneurysmsurveillance'.)
Mostpatientswhopresentwithacuteabdominalcomplaintswillundergoinitiallaboratorytestingthatincludesa
completebloodcount,electrolytes,bloodureanitrogenandcreatinine.Thosewhopresentinshockwillundergo
additionalstudiesincludingliverfunctiontests,coagulationparameters,fibrinogen,fibrinsplitproducts,arterialblood
gases,alactatelevel,cardiacenzymes,andtoxicologystudies.
Anemiaandmetabolicacidosismaypointtowardacutebloodlossasthecauseofshockrelatedtoaruptured
AAA.
Anelevatedwhitebloodcellcountmayindicateaorticinfectionorinflammationinpatientswhopresentwith
systemicmanifestations(eg,fever,weightloss).Additionalstudiessuchasbloodculturesandanerythrocyte
sedimentationratemaybeusefulfordistinguishinginfectedorinflammatoryAAAfrommorecommon
aneurysms.TheESRcanbemarkedlyelevatedinpatientswithinflammatoryAAA.
AlthoughmostpatientswithrupturedAAAhavenormalcoagulationtests,somemayhavecoagulopathy[71].
Laboratoryevidenceofdisseminatedintravascularcoagulationmayberelatedtoalargeorextensive
aneurysm,suchasathoracoabdominalaneurysm(image11)[57,58].(See"Clinicalfeatures,diagnosis,and
treatmentofdisseminatedintravascularcoagulationinadults",sectionon'Diagnosticevaluation'.)
DIAGNOSISManypatientswithAAAandtheirphysiciansareunawarethatananeurysmispresent.Because
asymptomaticAAAcanprogresstorupturewithoutanyinterveningsymptoms,itisimportantthatadiagnosisof
AAAisconsideredinpatientswiththefollowing:
Nosymptoms,butwithriskfactorsforAAA.(See'History'above.)
PhysicalexaminationconsistentwithAAA(eg,pulsatileabdominalmass)orotherperipheralarteryaneurysm
(eg,femoral,popliteal).(See'Physicalexamination'above.)
Clinicalmanifestations(eg,abdominalpain,thromboembolism,others)potentiallyrepresentingasymptomatic
AAA(nonrupturedorruptured).(See'Symptoms'above.)
AlthoughAAAmaybesuspectedbasedupontheseclinicalfeatures,adefinitivediagnosisrequiresthe
demonstrationofafocal,aorticdilationmeetingthecriteriaforaneurysm(>1.5timesnormaldiameter)onimaging,
oratthetimeofabdominalexploration.(See'Aneurysmdefinitionandanatomy'above.)
Althoughanimagingdiagnosisisdesirable,itisnotanabsoluterequirementinthehemodynamicallyunstable
patientwithaknownAAAwhopresentswithclassicsymptomsandsignsofrupture(abdominal/back/flankpain,
hypotension,pulsatilemass).Inthisclinicalscenario,patientswhoarecandidatesforrepairaretakentothe
operatingroomforimmediatemanagement(intraoperativediagnosis)withoutaninterveningdiagnosticimaging
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study.(See"Managementofsymptomatic(nonruptured)andrupturedabdominalaorticaneurysm",sectionon
'Introduction'.)
Althoughanyimagingstudythatdemonstratesthefocaldilationcanbeusedtomakeadiagnosis,abdominal
ultrasoundandcomputedtomography(CT)oftheabdomenarethemostuseful.Eachmodalityissensitiveand
specificforestablishingadiagnosisofAAA[7274],butrecommendedunderdifferingclinicalcircumstances
(algorithm1),dependingupontheclinicalpresentation,andthehemodynamicstatusofthepatient.(See'Imaging
asymptomaticpatients'belowand'Imagingsymptomaticpatients'below.)
Otherimagingmodalities(eg,magneticresonanceimaging)(image12)arelessoftenusedintheinitialevaluationof
AAAbutmayplayaroleinselectedpatients,suchasinthepatientwithknownAAA(unrepairedorpostrepair)who
presentswithnewsymptomsorinpatientswhocannotreceiveintravenouscontrast[75,76].Conventional
arteriography,whichdemonstratesonlytheflowintheluminalchanneloftensurroundedbyluminalthrombus,isnot
accuratefordeterminingthediameteroftheaorta(image13).
ImagingasymptomaticpatientsForasymptomaticpatientsinwhomadiagnosisofAAAissuspectedonthe
basisofriskfactors,abdominalpalpation,orapriorimagingstudysuggestingAAA,abdominalultrasoundis
recommendedastheinitialdiagnosticmodality(algorithm1).
Ultrasoundisnoninvasive,inexpensive,andhasasensitivityof98percentandspecificityof99percentforthe
diagnosisofAAA[7274].Inprospectivestudies,ultrasoundhasbeenfoundtobeacosteffectivescreeningtoolfor
identifyingsmallaneurysms(<4.0cm)inpatientswithriskfactorsforAAA[77,78].(See"Screeningforabdominal
aorticaneurysm".)
Theroutinesonographicevaluationoftheaortainvolvesmeasuringtheanteroposterior(AP),longitudinal(image
14),andtransversedimensions(image15AB)ofthesuprarenal,juxtarenal,pararenalandinfrarenalaorta.Given
thecorrelationbetweenAAAandiliacarteryaneurysm,theexaminationshouldalsoincludeimagingoftheiliac
arteries.Patientsareaskedtofastpriortoundergoingtheexaminationtoreducethepresenceofoverlyingbowel
gasthatcanobscuretheaorta[79].Inapproximately1to2percentofcases,theaortacannotbeadequately
imagedbecauseoftechnicaldifficulties(eg,bowelgas,aorticdepth)[80].
Themainlimitationofabdominalultrasoundisthatitistechnicianandequipmentdependent[81].Iftheultrasound
probeisnotorientedperpendiculartothecenterline,theAPdiameteroftheaortamaybeoverestimated[82].There
remainsdebateovertheoptimalmethodofmeasuringthediameteroftheabdominalaorta(outertoouter,innerto
inner,orleadingedgetoleadingedge)[8385].Astudythatevaluatedthesemeasurementmethodsfoundthat
leadingedgemeasurementswerethemostreproducible,butallmethodsshowedahighdegreeofvariability[83].At
times,ultrasoundmaynotprovideanaccuratedepictionoftheiliacarteries,duetooverlyingloopsofbowel[80].If
theultrasoundstudyistechnicallyinadequaterelatedtothesefactors,anotherimagingstudyshouldbeobtained
(typicallycomputedtomography)(image16).
InasymptomaticpatientswhohaveundergoneascreeningstudyorhavebeendiagnosedwithAAAincidentallyasa
resultofanotherimagingstudy,itisimportanttodetermineiftheaortawasadequatelyimaged.Somescreening
protocolsprovideonlyalimitedevaluationoftheaorta.Iftheabdominalaortawasnotcompletelyimaged,imaging
didnotincludetheiliacarteries,orthemaximalAPdiameterwasnotmeasuredinaplaneperpendiculartoblood
flow,arepeatstudy,typicallyanotherabdominalultrasound,shouldbeobtained.
ImagingsymptomaticpatientsEstablishingadiagnosisofAAAinsymptomaticpatientsisguidedbythe
hemodynamicstatusofthepatient(algorithm1).
ForhemodynamicallyunstablepatientswithasuspectedruptureofaknownAAA,imagingishighlydesirable,butis
notabsolutelyrequiredpriortointervention.(See"Managementofsymptomatic(nonruptured)andruptured
abdominalaorticaneurysm",sectionon'Initialmanagement'.)
WhenrupturedAAAissuspectedbutthepresenceofananeurysmisNOTknownforcertain,wesuggest
ultrasonographytoconfirmthatananeurysmexists,ifimmediatelyavailable.Ultrasoundcanbeperformedatthe
bedsideorintheoperatingroomwhilethepatientisbeingresuscitatedwithoutcausinganunduedelayincare
(algorithm1).WithroutineuseoftheFocusedAssessmentwithSonographyinTrauma(FAST)exam,many
emergencydepartmentphysiciansarecomfortablewiththeabdominalultrasoundexamandcanquicklyidentifyan
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abnormallyenlargedaorta[22].Iftheaneurysmisruptured,retroperitonealhematomamayalsobeseen,butthe
rupturesiteisnotusuallyidentified.WhenAAAisidentifiedonultrasoundinapatientwithhypotensionand
abdominal/flank/backpain,apresumptivediagnosisofrupturedAAAcanbemade.
ForsymptomaticpatientssuspectedofhavingAAAwhoarehemodynamicallystable,werecommendurgent
abdominalCTratherthanultrasound(algorithm1).AbdominalCThastheadvantageofevaluatingtheabdomenin
moredetail,whichisnecessaryfordifferentiatingrupturedfromnonrupturedaneurysm,andCTisbetterthan
ultrasoundforevaluatingsuprarenalaneurysms(image17)[8689].AbdominalCTalsoreadilyidentifiesother
abdominalpathologiesasapotentialcauseofsymptoms[86].AbdominalCTdefinestheextentoftheaneurysm
providingimportantanatomicinformationbywhichtoplanurgentAAArepair,anddetermineswhethertheaneurysm
issuitedtoendovascularaneurysmrepair(EVAR)(image18)[8689].DisadvantagesofCTcomparedwith
ultrasonographyarethepotentialtooverestimatetheaorticdiameter,greatercost,therequirementforintravenous
contrast(whenCTarteriographyisrequired),andthecumulativeriskofradiationwithrepeatedscansinpatients
withknownAAA[75].AAAdiameteronCTscanshouldbemeasuredperpendiculartothecenterlineoftheaorta,to
avoidoverestimation,whichcanbeobtainedbyusingorthogonalmeasurementsorfacilitatedwithsemiautomated
software[90,91].
IntravenouscontrastisgenerallynotneededtoestablishadiagnosisofrAAA[92].However,manyvascularcenters
useabdominalCTwithintravenouscontrastorCTangiographywiththreedimensionalreconstructionforsuspected
rAAAinanticipationofpotentialendovascularrepair.However,inthesettingofvolumedepletion,theriskforrenal
dysfunctionisincreased.(See"Pathogenesis,clinicalfeatures,anddiagnosisofcontrastinducednephropathy".)
OncethepresenceofAAAisconfirmedonCT,aorticanatomymustbecarefullyevaluatedtodetermineifthe
aneurysmisruptured,orhassignsofinstabilitythatmayindicateimpendingrupture.Themaximalaorticdiameter
shouldalsobedeterminedandcomparedwithpriorstudies,ifavailable,toidentifypatientswhomighthavearapidly
expandinganeurysm(0.5cm/year).Inaddition,theaorticwallshouldbeevaluatedtodeterminewhetherthe
aneurysmappearstobeinfectedorisconsistentwithaninflammatoryaneurysm.Lastly,forsymptomaticpatientsin
whomAAAispresentbutclearlynotruptured,ajudgementmustbemadeastowhethertheaneurysmisthemost
likelycauseforthesymptomsinthecontextofotherpathologythatmaybepresentonimaging.Theseissuesare
discussedmorefullybelow.
RupturedversusnonrupturedAAADifferentiatingasymptomaticbutnonrupturedAAAfromananeurysm
thatisabouttoruptureorisintheprocessofrupturingiscriticalandisaccomplishedusingcomputedtomography
(CT)oftheabdomen,whichishighlyaccurate[93].SignsonCTassociatedwithrupturedAAAandAAAthatmay
beunstableandatriskforimpendingrupturearediscussedbelow(table1).Althoughruptureisunlikelyinpatients
whohavenoneofthefeaturesdescribed,symptomaticpatientswithAAA,particularlyinthosewithmoderateto
largesizedaneurysm,aretypicallyadmittedandobservedwhenanotheretiologycannotbedetermined.TheAAA
shouldbeconsideredasymptomaticAAA,untilprovenotherwise.Themanagementofsymptomatic,nonruptured
AAAisdiscussedelsewhere.(See"Managementofasymptomaticabdominalaorticaneurysm",sectionon
'Introduction'.)
InthesettingofrupturedAAA,theriskforcontrastinducednephropathyisincreasedinthesettingofvolume
depletionwhenintravenouscontrastisused.(See'Imagingasymptomaticpatients'aboveand"Preventionof
contrastinducednephropathy".)
Inpatientswithacutesymptomslastingmorethanonehour,findingsofAAAruptureonCTscanareusuallyobvious
[94].CTscanfindingsconsistentwithrupturedAAAincludethefollowing:
Retroperitonealhematoma(image19andimage20)
Indistinctaorticwall(image21)
Retroperitonealstranding(image21)
Lossofthefatplanebetweentheaortaandsurroundingtissue(image22)
Extravasationofintravenouscontrastoutsidetheaorta(intoretroperitoneum,intoavein,intobowel)(image23
andimage8andimage7)
SomepatientswithAAAandabdominalpainhaveCTscansthatfailtoshowsignsofovertaorticrupture.Other
findingsonabdominalCTthatmaybeassociatedwithpotentiallyunstableaneurysmsorpossibleimpending
https://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofabdominalaorticaneurysm/print?source=search_result&search=aneurisma&sel
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ruptureincludethefollowing[86,9599]:
Acrescentsignoflayeringhematomawithintheaorta(image24)
Aorticblebsthatbulgefromthesurfaceoftheaorta(image25)
Drapingoftheaortaoveravertebralbody
Irregularityoftheaorticwall
Breaksinthecalcificationoftheaorticwall(image20)
Localizedareasofhigherattenuationwithinmuralthrombus(image22)
TheseimagingabnormalitieswereinitiallydescribedinaretrospectivereviewofpatientswithrupturedAAA
comparedwithnonrupturedAAA.Alaterprospectivestudyfoundonlya7percentpositivepredictivevaluefor
subsequentAAAruptureusingthesefindings[95].AlthoughtherearenospecificCTscanfindingsthatdefinitively
predictrupture,thesesignsofimpendingruptureincombinationwithanAAAof>5cmmayindicateananeurysm
thatisrapidlychanginganatomically[100].
AresymptomsrelatedtoAAA?InpatientswithsymptomaticbutclearlynotrupturedAAA,thequestion
alwaysarisesastowhethertheaneurysmisthesourceofthesymptoms.Imagingthatdemonstratesapathology
thatismoreconsistentwiththepatientssymptoms(eg,renalcolic)mayindicatethattheAAAistheincidental
finding.
However,ifthepresentingsymptomsarenottypicalforotherpathologiesidentifiedonCT,oranotheretiology
cannotbeclearlydetermined,andthesymptomsareconsistentwiththoseassociatedwithAAA,thenthepatientis
regardedashavingasymptomaticAAA,untilprovenotherwise.Thisdeterminationusuallyrequiresadmissiontothe
hospitalandobservation,whileundergoingfurtherstudies.Insomepatientswithsymptomatic,nonrupturedAAAin
thesettingofhypertension,bloodpressurecontrolmaysometimesalleviatepain.(See"Managementof
asymptomaticabdominalaorticaneurysm",sectionon'Introduction'.)
Forpatientswhopresentwithlowerextremityembolism,featuresoftheaortaonCTthatsuggestthattheaneurysm
maybethesourceembolismincludeanirregularluminalsurface,multipleaorticlumens,heterogeneityoftheaortic
thrombus,calcificationwithintheaorticthrombus,andfissuresextendingfromthelumenintotheaorticthrombus
[49].Inaddition,thepresenceoftypicalfeaturesofembolizationinthedistalvasculatureintheabsenceof
atheroscleroticperipheralarterydiseaseinapatientwithAAAandnootherproximalsourceforembolus(eg,atrial
fibrillation)suggeststhattheaneurysmisthesource.
InfectedversusinflammatoryAAAInflammationisacommoncomponentofmostaorticaneurysms,butthe
typicalAAAmustbedistinguishedfromaneurysmsthatareinfected,aswellasadistinctclinicalentitycalledan
inflammatoryaneurysm[5,53].Themanagementoftheseaneurysmsubtypesdiffersfromnoninfected,
noninflammatoryAAAs.
Althoughclinicalfeaturesofnonspecificabdominalpainassociatedwithsystemicsymptoms(eg,fever,malaise)and
apulsatileabdominalmassmaysuggestadiagnosisofaninfectedorinflammatoryAAA,specificfeaturesonCT
imagingmakethedistinction.
Primarybacterialinfectionoftheaorticwall,whichcanleadtorapidaorticexpansion,isararecauseofAAA.
PreexistingAAAcanalsobecomesecondarilyinfected[5,101].FindingsonCTsuggestiveofaninfected
aneurysmincludethefollowing[102108],whileotherclinicalfeaturesandthediagnosisofinfectedaneurysmis
discussedindetailelsewhere(see"Overviewofinfected(mycotic)arterialaneurysm"):
Saccular,eccentric,ormultilobulatedAAA
Softtissueinflammationsurroundingtheaorta
AAAwithintramuralair,oraircollectionaroundthevessel
Perivascularfluidcollection
Inflammatoryabdominalaorticaneurysm(IAAA),whichaccountsfor2to10percentofAAAs,ischaracterized
bythickeningoftheadventitiaduetomarkedinflammation[52,54,109111].Radiologically,anIAAAisdefined
asanAAAwitha1cmthickinflammatoryrindsurroundingtheaortaonabdominalCT[52].Theperiaorticsoft
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tissuedensitymayenhancewhenintravenouscontrastisadministeredandtheretroperitonealtissueplanes
betweentheaortaandretroperitoneumareindistinct.OtherfeaturesconsistentwithIAAAarefibrosisofthe
adjacentretroperitoneum,adherenceoftheanterioraspectoftheIAAAtoadjacentstructures(eg,duodenum,
ureters),andmedialdeviationoftheureters(image6).Inflammatoryaneurysmsarenotassociatedwith
periaorticairorfluid,andalthoughinflamed,theseaneurysmsarenotinfected.(See"Managementof
asymptomaticabdominalaorticaneurysm",sectionon'Introduction'.)
DIFFERENTIALDIAGNOSISAorticpathologiesthatcanproducesymptoms,particularlyabdominalorflankpain
similartoAAA,includeaorticdissectionandaorticpseudoaneurysmduetoerosionofulceratedplaque.Thepain
fromaorticdissectionisdescribedassearingandoftenbeginsinthechest,migratingintotheabdomenovertime.
Aorticdissectionmayaffectotherarchvesselsleadingtoothersymptoms(cerebralembolism,upperextremity
ischemia),thatwillnotbepresentinpatientswithAAA.Inpatientswithulceratedaorticplaque,thesymptomsmay
beindistinguishablefromrupturedAAA.Visceralaneurysmrupturemayalsomimicrupturedabdominalaortic
aneurysm[112].(See"Clinicalfeaturesanddiagnosisofacuteaorticdissection".)
AorticimagingwilldifferentiatetheseetiologiesfromAAAhowever,imagingprotocolsvary.Thus,ifthereisany
questionthataorticpathologymayinvolvethethoracicaorta,simultaneouschestandabdominalimagingshouldbe
obtainedratherthanabdominalimagingalone.(See"Overviewofacuteaorticsyndromes",sectionon'Diagnosis'
and"Clinicalfeaturesanddiagnosisofacuteaorticdissection",sectionon'Diagnosis'.)
ThepainfromsymptomaticorrupturedAAAcanmimicmanyotherconditionssuchasrenalcolic,coronary
ischemia,diverticulitis,pancreatitis,mesentericischemia,andbiliarytractdisease,tonameafew.Thegeneral
approachtoabdominalpainandtheextensivedifferentialdiagnosisofabdominalpainarediscussedelsewhere.
(See'RupturedAAA'aboveand"Evaluationoftheadultwithabdominalpain"and"Causesofabdominalpainin
adults".)
Forpatientswithriskfactors,abdominalsymptoms,oraphysicalexaminationthatinanywaysuggestsAAA,the
mostpracticalapproachisexpedientabdominalimaging[38],eventhoughthepatientmayhaveahistoryofanother
medicalconditionthatcouldaccountfortheirsymptoms.Inastudyof152patients,rupturedAAAwasinitially
misdiagnosedasrenalcolic,perforatedviscus,diverticulitis,gastrointestinalhemorrhage,orischemicbowelin30
percentofthepatients,baseduponclinicalsymptomsandsignsalone[34].Withimaging,theabsenceofaortic
dilationrulesoutAAA.IfAAAispresent,butclearlynotruptured,adeterminationwillneedtobemadewhetheror
notthesymptomsareduetotheAAA.(See'AresymptomsrelatedtoAAA?'above.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyondthe
Basicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe
10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewith
somemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patienteducation:Abdominalaorticaneurysm(TheBasics)")
BeyondtheBasicstopics(see"Patienteducation:Abdominalaorticaneurysm(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Abdominalaorticaneurysm(AAA)isdefinedasafocal,fullthicknessdilationoftheaortathatismorethan50
percentgreaterthanitsnormaldiameter.Theabdominalaortabelowtherenalarteries(infrarenal)isthemost
commonsiteforaorticaneurysm.Intheinfrarenalaorta,amaximumdiameter3.0cmisaneurysmalinthe
majorityofpatients.(See'Aneurysmdefinitionandanatomy'above.)
MostpatientswithAAAdonothaveanysymptoms.AsymptomaticAAAmaybediscoveredasaresultof
screeninginpatientswithriskfactorsforAAA,onroutinephysicalexamination,oronimagingstudiesto
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evaluateanunrelatedcomplaint.(See'Clinicalpresentations'above.)
ThepatientsmedicalhistoryidentifiestheriskfactorsfordevelopingAAA,andriskfactorsassociatedwith
rupture.ThepatientandtheirfamilymembersshouldbeaskedwhetheradiagnosisofAAAhasbeen
establishedinthepastoraskedifapriorAAArepairhasbeenperformed.Thehistorymayalsohelpdetermine
ifclinicalmanifestationsarelikelyrelatedtoapossibleAAAversusanothermedicalcondition.Symptoms
potentiallyrelatedtoAAA(eg,pain)canmimicmanyotherdiseaseshowever,inpatientsknowntohave,or
subsequentlyshowntohaveAAA,symptomsarepresumedtobeduetotheaneurysmuntilunequivocally
provenotherwise.(See'History'aboveand'AresymptomsrelatedtoAAA?'above.)
AAAdoesnottypicallycausesymptomsunlesstheaneurysmisexpandingrapidly,hasbecomelargeenoughto
compresssurroundingstructures,isaninflammatoryorinfectiousaneurysm,orhasruptured.Patientswith
symptomaticAAAmostcommonlypresentwithabdominal,back,orflankpain,whichmayormaynotbe
associatedwithAAArupture.Theclassictriadofacuteabdominalpain,abdominaldistention,and
hemodynamicinstabilityispresentinabout50percentofpatientswithrupturedAAA.AAAcanalsopresent
withotherclinicalmanifestationssuchaslimbischemia(acuteorchronic),orothersystemicmanifestations
(fever,malaise).(See'Symptoms'above.)
ThesoleuseofabdominalpalpationcannotbereliedupontodiagnoseorexcludeAAA.Abdominalpalpationis
about70percentsensitiveoverallforthedetectionofAAA.Thesensitivityofpalpationincreaseswithincreasing
AAAdiameterandisaffectedbytheabdominalgirthofthepatient.Forpatientswithanabdominal
circumference<40inches(100cm),thesensitivityofabdominalpalpationapproaches100percentforthe
detectionofAAA5.0cm.(See'Abdominalpalpation'above.)
AlthoughAAAmaybesuspectedbaseduponriskfactors,abdominalpalpation,orclinicalmanifestations,a
definitivediagnosisrequiresabdominalimagingstudiesthatdemonstrateafocal,aorticdilationmeetingthe
criteriaforaneurysm(>1.5timesnormaldiameter).Abdominalultrasoundandcomputedtomographyofthe
abdomenarebothhighlysensitiveandspecificfordiagnosingAAA,butarerecommendedunderdiffering
clinicalcircumstances(algorithm1),dependinguponthepresenceofsymptoms,andthehemodynamicstatus
ofthepatient.
Formostasymptomaticpatients,werecommendabdominalultrasoundastheinitialdiagnosticmodality.
UltrasoundisnoninvasiveandcosteffectivefordiagnosingAAAinasymptomaticpatients.(See'Imaging
asymptomaticpatients'above.)
Formostsymptomaticpatientswhoarehemodynamicallystable,werecommendcomputedtomographyof
theabdomenastheinitialdiagnosticmodality.AbdominalCTprovidesadditionalanatomicdetailthat
identifiesrupturedaneurysm,infectedaneurysm,inflammatoryaneurysm,andotherfeaturesthatare
importantinthesubsequentmanagementofsymptomaticAAA.AbdominalCTmayalsoidentifyother
pathologiesthatmaybethesourceofsymptoms.(See'Imagingsymptomaticpatients'above.)
ForhemodynamicallyunstablepatientssuspectedofhavingrupturedAAA,whereadiagnosisofAAAis
NOTpreviouslyknown,wesuggestafocusedultrasonographyexam(bedside,operatingroom)toconfirm
thatananeurysmexistspriortoexploration,provideditisimmediatelyavailable.Patientswithaknown
AAA,whopresentwithclassicsymptomsandsignsofrupture,aregenerallytakenforrepairwithout
preoperativeimaging.(See'Imagingsymptomaticpatients'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
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Topic15229Version23.0
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GRAPHICS
Anatomyabdominalaorticaneurysm
Graphic60682Version13.0
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Aortogramnormalaortaandinfrarenalaorticaneurysm
Thenormalaortogram(A)iscontrastedwiththeaortogramofapatientwithalargeinfrarenalabdominal
aorticaneurysm.Thearrowspointtotherightrenalarteryinbothimages.
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CTscaninfrarenalaorticaneurysmwiththrombus
A4cminfrarenalAAAisshownontheaxialCTimagespriorto(A)andfollowingadministrationof
intravenouscontrast(B).Luminalthrombus(arrowhead)isseensurroundingtheflowchannel.Thecoronal
CTreconstruction(C)showsthelowdensitycircumferentialthrombus(arrows)surroundingthecontrast
filledlumen.
CT:computedtomographyAAA:abdominalaorticaneurysm.
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Pararenalabdominalaorticaneurysm
Alarge6by5.4cmpararenalAAAcanbeseeninthecoronalCTreconstruction(A)encroachingon
therightrenalartery(arrow).Inthecrosssectionalimages,therightrenalartery(arrowinB)andthe
leftrenalartery(arrowinC)canbeseen.
AAA:abdominalaorticaneurysmCT:computedtomography.
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Normalabdominalaorta
Theabdominalaortaisaretroperitonealstructurethatbeginsatthehiatusof
thediaphragmandextendstoitsbifurcationintotherightandleftcommoniliac
arteriesatthelevelofthefourthlumbarvertebra.
Thebranchesoftheabdominalaortainclude(superiortoinferior)theleftand
rightinferiorphrenicarteries,theceliacaxis,leftandrightmiddlesuprarenal
arteries,superiormesentericartery,leftandrightrenalarteries,leftandright
gonadalarteries,inferiormesentericartery,leftandrightcommoniliacartery,
andmiddlesacralartery.Thepairedlumbararteries(L1L4)branchfromthe
aortaatmidvertebralbody.
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Arteriomegalyandaneurysmaldisease
Thepredispositiontomulticentricaneurysmaldiseaseintheaortaandperipheralarteriessuggestsa
diagnosisofarteriomegaly.TheCTscanthroughthelowerabdomen(A)showsanabdominalaortic
aneurysm(AAA)(arrow).Inthepelvis(B),aneurysmsofthecommoniliacarteriescanbeseen,largeron
theright(arrow)thantheleft.Inthelowerextremities(CandD),ectaticfemoralarteries(bilateral
arrows,C),andbilateralpoplitealaneurysms(bilateralarrows,D)areseen.Therightpoplitealaneurysm
islobulated(arrowhead).
CT:computedtomography.
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Symptomaticabdominalaorticaneurysmwithrapidexpansion
AninfrarenalAAAisshownovera17monthperiod.TheearliestaxialCT(A)showstheAAAmeasuring5
cm.Tenmonthslater,theAAAismarginallylargerandmeasures5.2cmindiameter.Sevenmonthslater,
thepatientpresentedwithleftlowerquadrantpainandatenderaneurysmnowmeasuring6cmonCT
scan(C).Anewdeformityintheanteriorabdominalwallisidentifiedanteriortotheaorta(arrow)caused
bytherapidlyexpandinganeurysm,whichhasanincreasedriskforrupture.
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Rapidexpansionofabdominalaorticaneurysmonultrasound
Theultrasoundimageswereperformedsixmonthsapartandshowrapid(>0.5cm)expansionofan
abdominalaorticaneurysm(AAA)(AtoB)andadvancinghydronephrosis(whitearrow)(Cto
D).Perianeurysmalfibrosiswithsecondaryprogressiveureteralobstruction,aswouldbeseenwithan
inflammatoryaneurysm,couldexplainthesefindings.
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Abdominalaorticaneurysmwithaortocavalfistula
Theaortograms(A,Credoverlay)showasaccularinfrarenalaorticaneurysm.Premature
fillingoftheinferiorvenacava(B,Dblueoverlay)isconsistentwithanaortocavalfistula,
whichisduetoAAArupture.
AAA:abdominalaorticaneurysm.
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Aortoduodenalfistula
TheCTscancomesfroma75yearoldpatientwithahistoryofAAArepairwhopresentedwithmassive
lowergastrointestinalbleeding,andhypotension.AnaortoduodenalfistulaisdemonstratedbyaCTscan,
whichshowsabreakinthewalloftheaorta(arrow)andhighdensityhematomaintheaorta
(arrowhead).InimageB,aircanbeseentrackingbetweentheduodenumandtheaorta(arrow).
CT:computedtomographyAAA:abdominalaorticaneurysmGI:gastrointestinal.
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GreyTurnersign
GreyTurnersignreferstoflankecchymosesthatresultfrombloodtrackingsubcutaneouslyfroma
retroperitonealorintraperitonealsource.
Reproducedfrom:MashaL,BernardS.GreyTurner'ssignsuggestingretroperitonealhaemorrhage.Lancet
2014383:1920.IllustrationusedwiththepermissionofElsevierInc.Allrightsreserved.
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Periumbilicalecchymosis
(A)Reddishdiscoloration,thesocalledCullen'ssign,wasseenaroundthepatient'sumbilicus.
(B)Intraoperativefindings:markedhemorrhageinthemesocolonwasseen.
Reproducedwithpermissionfrom:SugimotoH,InoueS,OkochiO,etal.Cullen'sSigninPancreaticTrauma.
Pancreas200224:408.Copyright2002WoltersKluwerHealth,LippincottWilliams&Wilkins.Unauthorized
reproductionofthismaterialisprohibited.
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CTscaninfrarenalaorticaneurysmwitheccentricthrombus
TheaxialCTimageshowsaninfrarenalabdominalaorticaneurysm,whichmeasures3.2cm.
Eccentricmuralthrombusisseenadjacentthecontrastenhancedlumen(arrow).
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TypeIVthoracoabdominalaneurysmonCTscan
ACTscanintheaxialprojection(A)andreconstructedinthesagittalprojection(B)showectasiaof
thedistalthoracicaorta(arrowsAandB).ImageCisanaxialprojectionandImageDa
reconstructedsagittalprojectionoftheabdominalaortaandshowa6.2cmaneurysm(arrowsCand
D)withalargeamountofluminalthrombus(arrowheadsCandD).
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Algorithmforthediagnosisofabdominalaorticaneurysm
AAA:abdominalaorticaneurysmH/P:historyandphysicalCT:computedtomographyOR:operatingroomMRI:magnetic
resonanceimaging.
*SystolicBPpersists<90mmHg,inspiteofresuscitation.
Intravenouscontrastisnotabsolutelyrequiredtodiagnoserupture,butishighlydesiredifendovascularrepairisanoption.
Unrepaired,orprioropenorendovascularrepair.
Ultrasound,abdominalCT,orMRImaybeappropriate.
Canbeperformedatthebedsideorintheoperatingroom.
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InfrarenalabdominalaorticaneurysmonMRIandCTscan
TheT1weightedMRIsequence(A)showsa4cminfrarenalAAA.Thesameaneurysmisalsoshownona
contrastenhancedCTscan(B).CTishighlysensitiveforevensmallamountsofcalcium(arrow),whereas
thelackofsensitivityofMRIforcalcificationlimitsaccuratemeasurementandcharacterizationof
changesintheaorticwall.
AAA:abdominalaorticaneurysmCT:computedtomographyMRI:magneticresonanceimaging.
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AortogramandCTscanofinfrarenalabdominalaortic
aneurysm
Thedigitalsubtractionaortogram(A)showsafusiformAAA(arrow).The
contrastcolumnshowstheluminaldiameterandnotthetruediameterofthe
aneurysm.AorticdiameterisbestevaluatedoncrosssectionalCT,whichshows
theoutsidemarginoftheaorticwall(B).Notethatthereisalargeamountof
eccentric,muralthrombuswithintheaorta(arrow)ontheCTscan.Also,a
horseshoekidneyisquiteobviousontheCTscan(arrowhead)butisonly
vaguelyoutlinedonthearteriogram(blackarrowsinpanelA).Thepresenceofa
horseshoekidneymayaltertheapproachtoAAArepair.
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Ultrasoundofnormalabdominalaortaandaorticaneurysm
Theultrasoundinlongitudinalviewshowsanormalabdominalaorta(A),whichiscontrastedwithasimilar
viewofanaortainapatientwitha7.7cminfrarenalabdominalaorticaneurysm(B).
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Abdominalaorticaneurysmonultrasound
Routinesonographicevaluationofanabdominalaorticaneurysminvolves
measuringtheanteroposterior,longitudinal,andtransversedimensionsofthe
aorta.Inthisinstance,thediametersinthetransversedimensions(5.75and
5.43cm)aremuchgreaterthannormal(typicallyaround2cmorless).
Thrombusorechodensecalcifications(arrow)inoradjacenttotheaorticwall
mayalsobevisualized.
CourtesyofEmileRMohlerIII,MD.
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Abdominalaorticaneurysmlongandshortaxis
(A)Thelongaxisviewshowsananeurysmoftheabdominalaorta(AAoAn)as
theaortacrossesthediaphragm.Prominentplaquesjustbeyondtheaneurysm
canbeappreciated.
(B)Theshortaxisthroughtheaneurysm(An)alsoshowstheinferiorvenacava
(IVC).
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Abdominalaorticaneurysmextendingtotheiliacbifurcation
TheaxialcontrastenhancedCTshowsthattheabdominalaorticdiameterisnormalatthelevelofthe
renalarteries(A,arrow),andwellbelowtherenalarteries(B).Afusiformdilation(C)beginsatthelevel
orthethirdlumbarvertebraandextendstotheiliacbifurcation(D)butdoesnotextendintothe
commoniliacarteries.Thesagittalview(E)showsthedistalfusiformaneurysmwithluminalthrombus.
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ThoracoabdominalaorticaneurysmonaxialCT
TheseriesofaxialCTimagesshowsadistalthoracoabdominalaorticaneurysm.Theaneurysmalsegment
ofthesuprarenalaorta(arrows)contraststothenormaldiameterinfrarenalaorta(arrowhead,C).
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Abdominalaorticaneurysmonthreedimensionalimaging
ThethreedimensionalrenderedCTimagesshowa5.2cminfrarenalabdominalaorticaneurysm(between
whitearrows).Theaneurysmoriginates2.3cmbelowtherenalarteriesandterminates1.9cmabovethe
iliacbifurcation.
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FeaturesofrupturedabdominalaorticaneurysmonCT
Abdominalaorticrupture
Retroperitonealhematoma
Indistinctaorticwall
Retroperitonealstranding
Lossoffatplanebetweentheaortaandsurroundingtissue
Extravasationofcontrast
"Impending"rupture
Crescentsignlayeringhematoma
Aorticblebs
Drapingoftheaortaoveravertebralbody
Irregularaorticwall
Breaksincalcificationoftheaorticwall
Localizedareasofhigherattenuationwithinmuralthrombus
Source:ChienDK,ChangWH,YehYH.Radiographicfindingsofarupturedabdominalaorticaneurysm.Circulation2010
122:1880.
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Rupturedabdominalaorticaneurysm
TheCTscanoftheabdomenshowsanacuteruptureofa5cminfrarenalabdominalaorticaneurysm.The
highdensityacutebloodobliteratestheperiaorticfatplane(arrowinA).Theblooddissectsintothe
retroperitoneumandobliteratesthefatplanearoundtheIVC(arrowhead)andtherightpsoasmusclein
theposteriorpararenalspace(dashedarrow).Thehighdensityacutebloodisbetterappreciatedwith
narrowedwindows(arrowinB).Thefullextentofthebleedisdemonstratedbythemaroonoverlayin
imageC.TheaneurysmisoverlaidinbrightredandthecompressedIVCinblue.
CT:computedtomographyIVC:inferiorvenacava.
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Rupturedabdominalaorticaneurysmoncomputedtomography
Aorticcalcificationidentifiestheintactwalloftheaorta.Alargeheterogenous
retroperitonealhematomaispresentadjacenttheleftkidneyatthesiteofrupture.
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Largerupturedabdominalaorticaneurysm
Aruptured9.6cminfrarenalabdominalaneurysmofa70yearoldmalewithpainandhypotensionis
shownintheaxialCTimage.Blooddissectsintotheleftsidedposteriorpararenalspace,perirenalspace,
andintoGerota'sfascia(arrowinA).Thesiteofrupture(arrowinB)isnotedmoreinferiorly.
CT:Computedtomography.
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Rupturedabdominalaorticaneurysmlaminatedthrombus
ThenoncontrastCTscan(A)showscontainedruptureofa9cmaorticaneurysmwithlayersof
extraluminalhighdensityacutehemorrhage(arrow)intheanteriorpararenalspaceconsistentwith
rupture.Onthecontraststudy(B),thelikelypointofruptureisseen(arrow)adjacenttoasmallamount
ofextravasatedcontrast(arrowhead).
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Rupturedabdominalaorticaneurysmwithcontrastextravasation
Arupturedinfrarenalaorticaneurysmisidentifiedwithacuteextravasationofcontrastbetweenthe
layersofchroniclaminatedthrombus.Extravasatedbloodcanbeseenintheposteriorpararenalspace
(arrow),perirenalspace(arrowhead),andintheanteriorpararenalspace(dashedarrow).Theright
kidneyisdisplacedposteriorly.
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Abdominalaorticaneurysmwithcrescentsign
Theseimagesshowalargeinfrarenalaorticaneurysmina77yearoldmale.Thelumenoftheaorta
canbeappreciatedinpanelA(arrow)andissurroundedbymuralthrombus.Ahyperdensecrescent
canbeseenwithinthethrombusinpanelB(arrowhead)suggestingacutehemorrhagewithinthe
thrombus.ThisfindingsuggestsanunstableAAAwithimpendingrupture.Narrowwindows(CandD)
areusedtoaccentuatethehighdensitycrescentsign(arrowheadinD).
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Abdominalaorticaneurysmwithbleb
Anunstablelargeinfrarenalaorticaneurysminthis90yearoldfemaleshowsafocalbulgeintheleft
lateralwalloftheaneurysm(whitearrow)suggestinganimpendingrupture.
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ContributorDisclosures
JeffreyJim,MD Consultant/AdvisoryBoards:Medtronic[Aorticinterventions(endovasculardevices)]. RobertW
Thompson,MD Nothingtodisclose JosephLMills,Sr,MD Grant/Research/ClinicalTrialSupport:Cesca
Therapeutics[Criticallimbischemia(Hepatocytegrowthfactor)]VoyagerTrial[Peripheralarterydisease
(Rivoxaraban)]NTA3CTAAATrial[Abdominalaorticaneurysm].Consultant/AdvisoryBoards:GoreBypass
Summit[Veinbypass(PTFEgraftsandendografts)].OtherFinancialInterest:ElsevierRutherford[Vascularsurgery
(RutherfordandComprehensiveVascularandEndovascularSurgerytextbooks)]. JohnFEidt,MD Nothingto
disclose EmileRMohlerIII,MD Grant/Research/ClinicalTrialSupport:NIH,PluristemandCelgene[PAD
(Mesenchymalstemcells)].PatentHolder:UniversityofPennsylvania[Cardiovascular(Vascularhealthprofileblood
test)].EquityOwnership/StockOptions:Cytovas[Cardiovascularbiomarker(Vascularhealthprofileblood
test)]. KathrynACollins,MD,PhD,FACS Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupport
thecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
evidence.
Conflictofinterestpolicy
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