IMAGING OF AORTIC ANEURYSM, DISSECTION

AND AORTOARTERITIS
• Aneurysm
– A localized abnormal
dilatation of an artery, vein,
or the heart.

• Aortic aneurysm
– thoracic
– abdominal
– thoracoabdominal
Risk factors
 Causes of aortic aneurysms
• Atherosclerosis(70-90%)
• Traumatic ( 15-20%)
• Congenital (2%)- aortic sinus, postcoarctation, ductus
diverticulum.
• Syphilis
• Mycotic
• Cystic medial necrosis( Marfan, Ehlers-Danlos 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 (often w/ iliac
& femoral arterial obstruction)
– Thoraco-abdominal

• Fusiform- 80%, saccular-20%

 Mycotic aneurysm
• Infected aneurysm (or mycotic aneurysm) is defined as an
infectious break in the wall of an artery with formation of a
blind, saccular outpouching that is contiguous with the arterial
lumen.

• Predisposing factors
– IV drug abuse
– Bacterial endocarditis (12%)
– Immuno-compromise (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)

• The most common cause of an infected aneurysm is direct deposition of

circulating bacteria in a diseased, atherosclerotic, or traumatized aortic
intima, after which organisms penetrate the aortic wall through breeches
in intimal integrity to cause microbial arteritis.
• Site
Ascending aorta > visceral artery > intracranial artery >
upper/lower extremity artery.

• Poor prognosis d/t quick expansion- rupture.

 Findings in mycotic aneurysm
1. Unusual location (noninfrarenal)
2. Saccular aneurysm
3. Irregular contour
4. Lack of calcification
5. Rapid enlargement
6. Signs of infection
– 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.

• Prevalence:
– Increases with age
– Greater with atherosclerotic disease
– Male predominance
– Whites: Blacks = 3:1
• Risk factors:
• male
• age >75 years
• white race
• prior vascular disease
• hypertension
• cigarette smoking
• family history
• hypercholesterolemia
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 are infrarenal

• Extension above renal arteries
– rare
• Extension to common iliac arteries
– fairly common (66-70%).
 Progression of AAA
• Over time, ~80% enlarge.
• Most enlarge slowly.
• Larger aneurysms enlarge faster.
• Smaller aneurysms enlarge slower.
– >=5cm 4-8mm/yr
– 4-5cm 3-7mm/yr
– <4cm 2-5mm/yr
 Imaging modalities
• Plain x-ray: (Curvilinear) mural calcifications (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
calcification.
 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 patient
– 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%)
– "crescent sign" = peripheral high-attenuating 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
• Major branch vessels proximally and distally-- helps in
determining the appropriate intervention (surgical or
endovascular repair). CTA -multiplanar assessment of the
aneurysm and associated relevant vessels (visceral arteries,
iliac and femoral arteries). This includes assessment for
congenital variants (accessory renal artery, retro/circumaortic
left renal vein.
• Assessment of other abdominal organs possible.
• Complications
 CECT- Large thrombus.
Small calcification in the thrombus
Angiogram underestimate the size of aneurysms in such case.
• Dilated abd aorta with mural
calcification.
Bilateral common iliac artery
aneurysm
 MRI
• MRI and MRA good
alternatives in
– Impaired renal function.
– Allergy to Iodinated
Contrast Media
 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.

 Angiography 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
Arteriogram -infrarenal
abdominal aortic
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
87-year-old man with 12-hour history of severe back pain. Enhanced axial CT images
reveal 7 x 9 cm abdominal aortic aneurysm with high-attenuation crescents within
mural thrombus (thick arrows). Contained rupture was present at surgery.
 CECT- Draped aorta sign: Posterior wall of the aneurysm is not seen and the
aneurysm extends around the vertebral body and on left paravertebral region
• Symptoms of rupture
– sudden severe abdominal pain ± radiating into back
– fainting, syncope, hypotension

• Prognosis: 64-94% die before reaching hospital

Ruptured aneurysm
• anterior displacement of
kidney
• extravasation of contrast
material
• fluid collection /
hematoma within
posterior pararenal +
perirenal spaces
• free intraperitoneal fluid
87-year-old man with known aneurysm and back pain. Enhanced CT image
shows anterior aneurysm rupture with associated retroperitoneal
hemorrhage.
False positive CT diagnosis 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.
 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
 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; and
(5) atypical aneurysms (eg, dissecting, mycotic, saccular).
 Endovascular repair such as stent-graft
placement
• Endovascular repair of an AAA involves gaining access to the
lumen of the abdominal aorta, usually via small incisions over
the femoral vessels.
• An endograft is placed within the lumen of the AAA extending
distally into the iliac arteries.
• This serves as a bypass and decreases the pressure on the
aortic wall, leading to a reduction in AAA size over time and a
decrease in the risk of aortic rupture.
• primary factors that undermine 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.
• Close follow-up is required after endovascular repair with CT
scans performed at one, six, and 12 months, and then yearly
to ensure that the graft is accomplishing its intended goal
(e.g., asymptomatic patient, decreasing AAA size, structurally
intact endograft, no fixation site problems or significant graft
migration).
 Thoracic aortic aneurysm
• Aneurysmal dilatation of ascending, arch, or descending
thoracic aorta.
• Aneurysm - localized or diffuse dilatation of more than 50% of
normal diameter of the aorta.
• A diameter >4 cm - aneurysm.
• A diameter >6 cm- usually an indication for surgery

• Normal diameter
– Aortic root 3.6 cm
– AA 1 cm proximal to arch 3.5 cm
– Prox des aorta 2.6 cm
– Middle des aorta 2.5 cm
– Distal des aorta 2.4 cm
 Anatomical classification
Type Cause

1. Aneurysm of sinus of 1.Congenital, Syphilis

Valsalva

2. Ascending aorta 2. Atherosclerosis, Marfan syn, Ehlers-

Danlos syn, syphilis, mycotic aneurysm

3. Arch of aorta 3. Atherosclerotic

4. Descending aorta 4. Atherosclerotic

5. Aortic isthmus 5. Post traumatic aneurysm

• Descending aorta aneurysms-most common 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 ( tracheobroncheal compression)
– Hoarseness (recurrent laryngeal nerve compression)
Imaging of thoracic aneurysms:
– Modalities:
» CXR
» CT/CTA
» MR/MRA
» TEE
» Aortography
 CXR
• Many readily visible on CXR.
• Findings
– (1) widening of the
mediastinal silhouette,
– (2) enlargement of the
aortic knob, or
– (3) displacement of the
trachea from the midline.
 TEE
– can be quickly performed at
bedside under sedation
without radiation or the
injection of contrast material.
– excellent at detecting
pericardial effusion and aortic
regurgitation
– 90% accuracy in imaging
intimal membranes for signs
of aortic dissection

• Disadvantage- poorly depicts

aneurysms below the diaphragm
and in the transverse aortic arch.
 CT/CTA
• primary diagnostic test of choice in most institutions
• reliable test for diagnosing aneurysm and dissection
• effective to define maximum diameter
• To monitor diameter over time.
• Findings:
– increase in aortic diameter
– outward displacement of calcium of the aortic wall.
 MR/MRA
• Alternative of CT/CTA specially in pt with
– impaired renal function
– allergy to Iodinated Contrast media.

• 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 aorto-annular abnormalities.
 Aortography
• The criterion standard until
late
• But rarely used now, with the
advent of helical
CT/MRI/MRA/TEE
• Still a modality for
– preop evaluation of
thoracic aortic aneurysms
– for precise definition of
the anatomy of the
aneurysm and great
vessels
 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
 Pathophysiology
• The essential feature of aortic
dissection is a tear in the intimal
layer, followed by formation and
propagation of a subintimal
hematoma.

• The dissecting hematoma

commonly occupies about half and
occasionally the entire
circumference of the aorta. This
produces a false lumen or double-
barreled aorta, which can reduce
blood flow to the major arteries
arising from the aorta.
• Aortic dissection often occurs along the right lateral wall of ascending
aorta and descending thoracic aorta just below the ligamentum
arteriosum.

• The dissection usually propagates distally down the descending aorta and
into its major branches, but it also may propagate proximally.
• Predisposing factors
– Starts in fusiform aneurysms in 28 % cases
– Hypertension (60-90%)
– Marfan syn
– Ehlers-Danlos syn
– Trauma
– Catheterisation
– Aortitis
 Clinical features:
1. Sudden onset of sharp, tearing, intractable chest pain, may radiate to
back, esp. interscapular region
2. Previously hypertensive, now possible shock (Signs of peripheral organ
blood flow hypoperfusion, including decreased urine output, ischemia
bowel, ischemia pain of lower extremities, etc.)
3. Asymmetric peripheral pulse
4. Diastolic murmur or bruit of aortic regurgitation
5. Pulmonary edema
6. Signs result from compression of adjacent tissues
 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
• CT Angiography
– Intimal flap – Intimal flap
– Displacement of intimal – Double lumen
calcification – Compression of true lumen
– Differential contrast by false channel
enhancement of true versus – Obstruction of branch
false lumen vessels
• MRI
– Intimal flap
– Slow flow or clot in false
lumen (lack of signal void)
• 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 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
 CLASSIFICATION SYSTEMS FOR AORTIC DISSECTION

Site of dissection Classification system

Crawford DeBakey Stanford
Both ascending and Proximal Type I (29-34%) Type A
descending aorta dissections
Ascending aorta and Proximal Type II (12-21%) Type A (70%)
arch only dissections
Descending aorta Distal dissections Type III (50%) Type B (30%)
only (distal to left IIIa—limited to
subclavian artery) thoracic aorta
IIIb—extends to
abdominal aorta
 Aortitis
Causes:
• Takayasu arteritis
• Giant cell arteritis (20% of
cases)
• Syphilis
– Begins above sinotubular
ridge
• Rheumatic fever
• Reiter’s syndrome
• Ankylosing spondylitis
– Crosses sinotubular ridge
and dilates both root and
ascending aorta Sinotubular Ridge-
Jnxn 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:
• The early phase –
– inflammatory -prepulseless phase
• 15-40 years – Present with constitutional sign and
• 8:1 females, symptoms with positive lab
• Early and late phases. findings(Increased ESR, positive C-
reactive protein).
• Presenting symptoms are Non- – Radiological findings show only
specific – thickened vessel wall on CT and MR.
– fever, – Angiography is usually negative.
– arthralgias, and • The late phase
– weight loss. – occlusive -pulseless phase.
• In pulseless phase- s/s of ischemia of – has thickening of media and
adventitia.
limb, renovascular hypertension.
– Angiographic findings show smooth
long segment stenosis and occlusions
of the proximal great vessels.
• A 5- to 20-year interval bet two phases.
Types of late-phase Takayasu
arteritis
On the basis of the sites of
involvement
•Type I - Branches of the aortic
arch
•Type IIa - Ascending aorta, aortic
arch, and its branches
•Type IIb - IIa + plus thoracic
descending aorta
•Type III - Thoracic descending
aorta, abdominal aorta, renal
arteries, or a combination
•Type IV - Abdominal aorta, renal
arteries, or both
•Type V - Entire aorta and its
branches
•Involvement of coronary arteries
and pulmonary arteries are
labelled as C+ and P+
respectively.
Preferred Examination
• Angiography - criterion-standard imaging

• CTA and MRA :Of late have become equally valuable tools.
• Adv of CTA and MRA over • Adv of MRI over CT
conventional angio: – Better soft-tissue contrast-
– large fields of view valuable in differentiating
– noninvasive nature active versus quiescent forms
– intravenously rather than of Takayasu disease.
intra-arterial contrast – No use of ICM
material
– increasing resolution of
MDCT.
– Particularly useful in pediatric
groups who are poor
candidates for conventional
angio.
 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.

• 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.
 48-year-old woman: Narrowing of the origin of the right subclavian artery and a
narrowed small vessel with subsequent aneurysmal dilatation on the right side– case
of Takayasu disease.
Aortogram of a 15-year-old girl with Takayasu arteritis. Note large aneurysms
of descending aorta and dilatation of innominate artery
32-year-old woman. CECT- thickening and enhancement of the wall of the
aorta at the level of the aortic arch (arrows)- case of Takayasu's arteritis
Coronal MRI of abdomen of 15-year-old girl with Takayasu arteritis. Note
thickening and tortuosity of abdominal aorta proximal to kidneys.
 Intervention
• Cyclophosphamide, 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.
• Stents
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