IMAGING OF AORTIC

ANEURYSM
AND AORTOARTERITIS

Aortic Aneurysms
Aneurysm
A localized abnormal dilatation of an
artery, vein, or the heart.

Aortic aneurysm
Thoracic
Abdominal
thoracoabdominal

Causes of aortic aneurysms

Atherosclerosis(70-90%)
Traumatic ( 15-20%)
Congenital (2%)- aortic sinus,
postcoarctation, ductus diverticulum.
Syphilis
Mycotic
Cystic media necrosis( Marfan, EhlersDanlos syndrome, annuloaortic ectasia)
Inflammation of media+adventitia-

Takayasu arteritis, Giant cell arteritis, Rheumatic fever,

Rheumatoid arthritis, Ankylosing spondylitis, Reiter
syndrome etc.

CLASSIFICATION

TRUE VS FALSE
True aneurysm all layers
False aneurysm contained by
adventitia or
perivascular connective tissue and organised hematoma.

FUSIFORM VS SACCULAR
Fusiform aneurysm
Circumferential involvement
Saccular aneurysm
portion of a wall

Atherosclerotic aneurysm
Cause - Atherosclerosis of the aorta
In elderly
Location
Descending aorta distal to Left SCA.
Infrarenal aorta (a/w thoracic aneurysm
in 29%)
Thoracoabdominal

Fusiform- 80%
Saccular-20%

Mycotic aneurysm
Induced by bacteria invading arterial
wall.
Predisposing factors
IV drug abuse
Bacterial endocarditis (12%)
Immunocompromise (malignancy,
steroids, chemo, DM, etc.)
Infected prosthetic valves or sternal wires

 Organisms
S. aureus (53%)
Salmonella (33-50%)
Streptococcus
Mycobacterium ( contiguous spread from
spine/lymph node)
site
Ascending aorta > visceral artery > intracranial
artery > upper/lower extremity artery.
Poor prognosis d/t quick expansion- rupture.
Imp to timely diagnosis bcz of poor prognosis.

Findings in mycotic aneurysm

1.
2.
3.
4.
5.
6.

Unusual location(noninfrarenal)
Saccular aneurysm
Rapid enlargement
Irregular contour
Lack of calcification
Signs of infection

Increase in periaortic fat

Perianeurysmal air
Perianeurysmal fluid collection with enhancing
wall
Enlarged perianeursymal lymph nodes
Osteomyelitis of adjacent vertebra

Images obtained in a 73-year-old man with infected infrarenal aortic

aneurysm associated with osteomyelitis and psoas muscle abscess.
(a) Transverse contrast-enhanced CT scan shows an infrarenal aortic
aneurysm (*) measuring 11 x 6 cm in diameter associated with a left
psoas muscle abscess (arrowhead) and vertebral body destruction
(arrow). (b) Sagittal T1-weighted MR image shows abnormal signal
intensity (arrow) in the bone marrow of the vertebral body.

Abdominal aortic aneurysm

Abdominal aortic aneurysms (AAAs)
are segmental dilatations of the aortic
wall that cause the vessel to be larger
than 1.5 times its normal diameter or
that cause the distal aorta to exceed
3 cm.
These can continue to expand and
rupture spontaneously, exsanguinate,
and cause death.

 Prevalence:
Increases with age
Greater with atherosclerotic disease
Male predominance
Whites: Blacks = 3:1

Associated with:
visceral + renal artery aneurysm (2%)
isolated iliac + femoral artery aneurysm (16%)
common iliac (89%), internal iliac (10%),
external iliac (1%)
stenosis / occlusion of celiac trunk / SMA (22%)
stenosis of renal artery (22-30%)
occlusion of inferior mesenteric artery (80%)
occlusion of lumbar arteries (78%)

 Clinical
asymptomatic (30%)
abdominal mass (26%)
abdominal pain (37%)

Anatomical classification
In relation to the renal arteries.
Suprarenal
Juxtarenal (within 1.5 cm of renal artery
origin)
Pararenal (involving one or both renal
arteries)
Infrarenal
~90-95% of AAAs -infrarenal
Extension above renal arteries
rare
Extension to common iliac arteries
fairly common (66-70%).

Enlargement of AAA

Over time, ~80% enlarge.

Most enlarge slowly.
Larger- faster.
smaller-slower
>=5cm
4-8mm/yr
4-5cm
3-7mm/yr
<4cm
2-5mm/yr

Imaging modalities
Plain x-ray: mural calcification (75-86%)

US initial screening
If the aneurysm is approaching 5 cm
or more or if rapid enlargement is
seen on serial US images
CT and CTA/ MR and MRA
Angiography

 Curvilinear calcification
(arrowheads) is consistent with
a significant size calcified
abdominal aortic aneurysm.

The lateral view clearly shows

calcification of both walls.
Abdominal aortic aneurysm can be
diagnosed with certainty- egg shell

USG
>98% accuracy in size measurement
screening examination of choice as a
result of its relative availability,
speed, low cost and no radiation.
Problems with
obese pt,
distended bowel with gas,
proximal iliac arteries

US findings
Focal dilatation
beyond normal.
Any increase in
the size as the
aorta travels
distally is
abnormal

 US findings of rupture
Partially encapsulated hematomas- a
hypoechoic or anechoic para-aortic
space-occupying lesion.
Color Doppler-site of leak or
extravasation,

CT-non-contrast
perianeurysmal fibrosis (10%), may
cause ureteral obstruction ( in
inflammatory aneurysm)
"crescent sign" = peripheral highattenuating crescent in aneurysm wall
(= acute intramural hematoma) = sign
of impending rupture

CT-contrast-enhanced
Accurately demonstrates dilation of the aorta
Extent of aneurysm
Degree of calcification, presence of mural
thrombus, whole aorta and iliac arteries
Major branch vessels proximally and distally-helps in determining the appropriate intervention
(surgical or endovascular repair).
Assessment of other abd organs possible.
CTA -multiplanar assessment of the aneurysm and
associated relevant vessels (visceral arteries, iliac
and femoral arteries).
complications

CECT- Large thrombus.

Angiogram underestimate the size of aneurysms in such case.

 Dilated abd aorta

with mural
calcification.

MRI
MRI and MRA
good alternatives
in
impaired renal
function and
allergy to ICM

Angiography
Often ordered for preoperative evaluation in
patients with manifestations of
atherosclerotic vascular disease such as

renal artery stenosis or

peripheral vascular disease.
The role of angiography is in planning
surgical or endovascular repair.
Largely replaced by CTA or MRA if available.

Angio findings
focally widened aortic lumen >3 cm
apparent normal size of lumen
secondary to mural thrombus (11%)
mural clot (80%)
slow antegrade flow of contrast
medium
In rupture- not usually done in
ruptured aneurysm.

 Arteriogram
-infrarenal
abdominal aortic
aneurysm.
This arteriogram
was obtained in
preparation of an
endovascular
repair of the
aneurysm

Lateral aortogram in a patient with severe mid back pain and

lumbar spine images which demonstrated anterior erosion of
the lower thoracic vertebral bodies. The angiogram
demonstrates that this has been caused by a pulsatile
thoraco-abdominal aortic aneurysm.

Complications:

Rupture (25%)
Peripheral embolization
Infection
Spontaneous occlusion of aorta

Rupture
Sites
into retroperitoneum: commonly on left
into GI tract: massive GI hemorrhage
into IVC: rapid cardiac decompensation

High risk for rupture of AAA

>5cm
Rapid growth ( >1cm per 6 months).
Mycotic aneurysm

Signs of AAA rupture

Primary sign
Periaortic stranding
Retroperitoneal hematoma
Extravasation of IV contrast

Secondary sign
High attenuating crescent sign
Focal discontinuity of intimal calcification
Tangential calcium sign
Draped aorta sign

High-attenuating crescent sign in a patient with subtle evidence of leak adjacent

to the right psoas muscle (broad arrow).

Foccal discontinuity of
intimal calcification

Tangential calcium sign:

Intimal calcification points
away from the aneurysm and
there is retroperitoneal
leakage.

LEFT: draped aorta sign.

RIGHT: two weeks later there is a rupture
A positive aortic drape sign is considered to be present when the following features are
seen:
area in which the posterior aortic wall is unidentifiable as a distinct line.
the posterior aorta follows the contour of the spine on one or both sides.

 Symptoms of rupture
sudden severe abdominal pain
radiating into back
faintness, syncope, hypotension

Prognosis:64-94% die before

reaching hospital

87-year-old man with known aneurysm and back pain.

Enhanced CT image shows anterior aneurysm rupture (black
arrow) with associated retroperitoneal hemorrhage (white
arrows).

False positive CT dx of aneurysm

rupture
Asymmetric aneurysm thrombus
Partial volume averaging of periaortic
tissue at the level of the aneurysm
neck.
Perianeurysmal fibrosis( in NECT)
Unopacified 3rd and 4th portion of
Duodenum.
Retroperitoneal lymphadenopathy.

Intervention
Open surgery
Endovascular repair

Open surgery- indications

(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 5 cm in diameter;
(4) complicated aneurysms with embolism,
thrombosis, or symptomatic occlusive disease.
(5) atypical aneurysms (eg, dissecting, mycotic,
saccular). These guidelines must be weighed
against the existing clinical risk factors in each
patient

Pre-op assessment of AAA

We should assess :
Maximum diameter of the aneurysm
Proximal and distal extent of aneurysm
Assessment of iliac and renal arteries
Perianeurysmal fibrosis
Congenital variations:
Accessory renal arteries
Retroaortic course of left renal vein

CT/CTA or MR/MRA is required for preop assessment.

USG is not enough because:
Perianeurysmal soft tissue can not be assessed
Relation with renal arteries & congenital variations are
difficult to assess

Endovascular repair such as

stent-graft placement
evolving as an alternative to
conventional, open surgical repair
primary factors that determine
suitability for endovascular repair are
diameter and length of the proximal neck
of the aneurysm- short and wide neck
poor fitting of stent.
tortuosity of the aorta- poor fitting and
anatomy of the iliac arteries- long and
large common iliac artery poor anchorage.

 Endovascular devices rely on radial

force to engage the more normal
segments of the aorta and iliac
arteries and to exclude blood flow
from the aneurysmal sac.

THORACIC AORTIC ANEURYSM

 Aneurysmal dilatation of ascending, arch, or

descending thoracic aorta.
Aneurysm - localized or diffuse dilatation of
more than 50% normal diameter of the
aorta.
Normal diameter
Aortic root
AA 1 cm proximal to arch
Prox des aorta
Middle des aorta
Distal des aorta

3.6 cm
3.5 cm
2.6 cm
2.5 cm
2.4 cm

Anatomical classicfication
Type

Cause

1. Aneurysm of sinus 1.Congenital, Syphilis

of Valsalva
2. AA
2. Atherosclerosis, Marfan
syn, Ehlers-Danlos syn,
syphilis, mycotic aneurysm
3. Atherosclerotic
3. AOA
4. Atherosclerotic
4. DA
5. Post traumatic aneurysm
5. Aortic isthmus

 Descending aorta aneurysms-m/c

Followed by ascending aorta
aneurysms
Arch aneurysms occur less often.
Descending aortic thoracic aneurysms
may extend distally to involve the
abdominal aorta and create a
thoracoabdominal aortic
aneurysm.

 Mean age 65 yrs

M:F 3:1
Clinical features
Substernal/back/shoulder pain
SVC syndrome( venous compression)
Dysphagia(oesophageal compression)
Stridor, dyspnea( tracheobrncheal com)
Hoarseness( recurrent laryngeal nerve
com)

Imaging of thoracic
aneurysms:
Main aim of imaging is to dx the
aneurysm and find out the complication(
dissection) as early as possible.
Modalities:
CXR
CT/CTA
MR/MRA
Transesophageal echocardiogram (TEE)
Aortography

CXR
Many readily visible on CXR.
Findings
(1) widening of the mediastinal
silhouette.
(2) enlargement of the aortic knob.
(3) displacement of the trachea from the
midline.

Chest radiograph showing widening of the

superior mediastinum.

 TEE
excellent at detecting pericardial effusion
and aortic regurgitation,
90% accuracy in imaging intimal
membranes for signs of aortic dissection
can be quickly performed at bedside
under sedation without radiation or the
injection of contrast material.
Disadv- poorly depicts aneurysms below the
diaphragm and in the transverse aortic arch.

CT/CTA
reliable test for diagnosing aneurysm and
dissection, CTA gives anatomy.
primary diagnostic test of choice in most
institutions
effective to define maximum diameter
To monitor diameter over time.
Findings:
increase in aortic diameter:
A diameter >4 cm - aneurysm.
A diameter >6 cm- usually an indication for surgery

outward displacement of calcium of the aortic

wall.

Computed tomography image as maximum-intensity-projection

showing calcification on the inner side of the aneurysm.

Ascending aortic aneurysm

MR/MRA
Alternative of CT/CTA specially in pt with
impaired renal function and
allergy to ICM

Velocity-encoded cine MRI

measurement of the differential flow
velocity in the true and false channels
to quantify the volume of concomitant
aortic regurgitation in patients with
aortoannular abnormalities.

Aortography
The criterion standard
But rarely used with the advent of
TEE and CT
Still the preferred modality for
preop evaluation of thoracic aortic
aneurysms
for precise definition of the anatomy of
the aneurysm and great vessels.

Ascending aortogram showing ascending

aortic aneurysm

Aortic
dissection

 Separation of the aortic intima with

tear in it communicating with the
true lumen.
True lumen-inside the intima
False lumen-outside the intima
Most dissections arise either just
distal to the aortic valve or just distal
to aortic isthmus

 Predisposing factors
Starts in fusiform aneurysms in 28 %
cases
Hypertension (60-90%)
Marfan syn
Ehlers-Danlos syn
Trauma
Catheterisation
Aortitis ( not syphilis)

CLASSIFICATION SYSTEMS FOR AORTIC

DISSECTION
Site of
dissection

Classification system
Crawford

DeBakey

Stanford

Both ascending
and descending
aorta

Proximal
dissections

Type I

Type A

Ascending aorta
and arch only

Proximal
dissections

Type II

Type A

Descending
Distal
Type III
Type B
aorta only
dissections
IIIalimited
(distal to left
to thoracic
subclavian
aorta
artery)
IIIbextends
Surgical
intervention is required for type A dissection.
In contrast, type B affects
to abdominal
only the descending aorta and generally require
only conservative medical
aorta
treatment.

True versus false channel

False lumen:

Anterior in the ascending aorta

larger caliber than true lumen
beak sign: acute angle with intimal flap at corner
intimal flap curved towards false lumen
thrombus is common
cobwebs due to medial strands
Slower flow in false channel on MR

True lumen:
continues with the lumen of nondissected
segment
Posterior and left lateral - descending aorta
smaller caliber
intimal calcification towards true lumen

61-year-old man with chest pain and acute type A aortic

dissection. Axial enhanced CT scan of ascending aorta shows
type A aortic dissection with intimomedial tear (arrows) entering
false lumen (F) from true lumen (T). DA = descending thoracic
aorta, PA = pulmonary artery.

41-year-old man with acute aortic dissection. CT scan obtained at

one-quarter distance along length of dissected portion of aorta
shows descending aortic dissection flap (arrows) that is curved
toward false lumen (F). Beak sign (arrowheads) is present in false
lumen. Note that false lumen area is larger than true lumen area

Clinical features:
Sharp, tearing, intractable chest pain
Murmur or bruit of aortic
regurgitation
Previously hypertensive, now
possible shock
Asymmetric peripheral pulses
Pulmonary edema

Imaging Findings
Chest X-ray:
o Mediastinal widening
o Displacement of intimal calcifications
o Apical pleural cap
o Left pleural effusion
o Displacement of endotracheal tube or
nasogastric tube

 MRI
Intimal flap
Slow flow or clot in false lumen

CT
Intimal flap
Displacement of intimal calcification
Differential contrast enhancement of true
versus false lumen

TEE
Intimal flap

TEE view of the descending thoracic aorta in the

horizontal plane. An aortic dissection is manifested by the
presence of a true lumen (TL), a false lumen (FL), and a
free-floating intimal flap (F). LA left atrium

Axial double-inversion-recovery MR images (TR/TE, 1875/18;

inversion time, 150 msec) of 37-year-old man with Marfan syndrome.
Image shows classic aortic dissection with double-channel aorta. True
lumen (straight arrow) is smaller than false lumen (curved arrow).
High-velocity flow in true lumen causes signal void. Slower flow with
higher signal can be seen in false lumen.

Angiography
Intimal flap
Double lumen
Compression of true lumen by false
channel
Increase in aortic wall thickness > 10
mm
Obstruction of branch vessels

AORTITIS

Causes of Aortitis

Takayasu arteritis
Rheumatic fever
Reiters syndrome
Syphilis
Begins above
sinotubular ridge

Giant cell arteritis

Ankylosing
spondylitis
Crosses sinotubular
ridge and dilates
both root and
ascending aorta

Sinotubular RidgeJct of Sinuses of Valsalva and

tubular aorta

Takayasu arteritis
granulomatous vasculitis of unknown etiology
commonly affects the thoracic and abdominal
aorta
causes intimal fibroproliferation of the aorta, great
vessels, pulmonary arteries, and renal arteries
results in segmental stenosis, occlusion, dilatation,
and aneurysm formation in these vessels.
Takayasu arteritis is the only form of aortitis that
causes stenosis and occlusion of the aorta.

 Pathophysiology:
not fully elucidated to date.
begins as a nonspecific, cell-mediated
inflammatory process in the patient's
first 2 decades of life and progresses to
the formation of fibrotic stenoses of the
aorta and its major branches.

Clinical Details:

15-40 years
8:1 females,
Early and late phases.
The early phase
inflammatory -prepulseless phase
Present with constitutional sign and symptoms with positive lab
findings(Increased ESR, positive C-reactive protein).
Radiological findings show only thickened vessel wall on CT and
MR.
Angiography is usually negative.
The late phase
occlusive -pulseless phase.
has thickening of media and adventitia.
Angiographic findings show smooth long segment stenosis and
occlusions of the proximal great vessels.
A 5- to 20-year interval bet two phases.
Presenting symptoms are Non-specific
fever,
arthralgias, and
weight loss.

Four types of late-phase

Takayasu arteritis
On the basis of the sites of
involvement
Type I aortic arch + brachiocephalic
arteries.
Type II thoracic aorta distal to arch,
abdominal aorta+ its major branches
Type III - Combination of type I and II
Type IV any portion of the aorta with
its branches + pulmonary artery.

Preferred Examination
Angiography - criterion-standard
imaging
CTA and MRA :In the last 5 years,
have become equally valuable tools.

 Adv of CTA and MRA over conventional

angio:
large fields of view,
noninvasive natures,
intravenously rather than intra-arterial
contrast material.
The increasing resolution of MDCT.
Particularly useful in pediatric groups who
are poor candidates for conventional angio.

 Adv of MRI over CT

Better soft-tissue contrast- valuable in
differentiating active versus quiescent
forms of Takayasu disease.
No use of ICM

Imaging Findings
Angiography: The angiographic features occur
late in the course of the disease and include
luminal irregularity
vessel stenosis, occlusion, dilatation, or aneurysms in
the aorta or its primary branches.
Neurofibromatosis of the abdominal aorta and some
other causes of mid aortic syndrome may produce an
identical angiographic picture in children.

CTA and MRA- thickened wall of aorta with

crescents and indistinct outlines
Associated aneurysms may be saccular or
fusiform.
USG/Doppler study in accessible vessels.
Shows wall thickness and stenosis.

Thoracic aortography in a young female with Takayasu aortoarteritis

demonstrates concentric stenoses involving the left common carotid and left
subclavian arteries (arrows).

TA in a 22-year-old woman. Contrast-enhanced CT images at the level of the aortic

arch (A) and at the level of the left pulmonary artery (B) demonstrate abnormal
concentric wall thickening and periaortic inflammation of the aortic arch, ascending
and descending aorta (arrows). (C) Sagittal reconstruction image demonstrates
abnormal wall thickening of the aortic arch branches (arrowheads).

Coronal MRI of abdomen of 15-year-old girl with Takayasu

arteritis. Note thickening and tortuosity of abdominal aorta
proximal to kidneys.

Intervention
Corticosteroid- acute phase
Bypass graft surgery is the procedure
with the best long-term patency rate
Percutaneous angioplasty:
C/I in acute phase.
Best results with short-segment stenoses.

Stent- reported in small numbers of

cases. Most of the time not successful.

QUESTIONS
1. Causes of aortic aneurysm.
2. Classification of aortic aneurysm.
3. Finding in mycotic aneurysm.
4. Benefits of CT contrast in AAA.
5.Angiographic findings in AAA.
6.Signs of AAA rupture.
7. Indications of open surgery in AAA.
8. Classification systems for aortic dissection.
9. Difference between true and false lumen.
10. Imaging finding in aortic dissection.
11. Imaging finding in Takayasu arteritis.