Pulsatile Abdominal Mass Research Articles

Ruptured Abdominal Aortic Aneurysm: A 7‐Year Retrospective Observational Study in an Emergency Department of Hong Kong

ObjectivesTo review the clinical presentations and outcomes of patients with ruptured abdominal aortic aneurysm (AAA) in a regional hospital and its evaluation in the accident and emergency department (AED).MethodsThis is a retrospective observational study of patients admitted through the AED with the discharge or post‐mortem diagnosis of ruptured AAA from 1st January 2002 to 31st December 2008 in a regional pubic hospital of Hong Kong. Their demographic and clinical data were recorded and analysed. The sensitivity of the AED in detecting ruptured AAA or symptomatic AAA was evaluated.ResultsTwenty‐six patients were found to have ruptured AAA and included in the study. All were Chinese. Seventeen patients had repair surgery done by open surgical method. Eighteen (69%) patients were diagnosed to have ruptured AAA or found to have symptomatic AAA in the AED. Three (12%) ruptured AAAs were diagnosed at post‐mortem. The most common presenting symptoms were abdominal pain (73%) and loss of consciousness (46%). Only five (19%) patients had the classical triad of abdominal pain, haemorrhagic shock and a pulsatile abdominal mass. Ultrasound of aorta was performed in 74% of cases in the group with ruptured AAA or symptomatic AAA diagnosed in the AED but none in the delayed diagnosis group (p=0.001). The former group were 3.7 times more likely to proceed to repair surgery (p=0.188) and had surgical repair operation 40.8 hours earlier than the latter group (p=0.006). Systolic blood pressure less than 90 mmHg at any time point before operation was found to correlate significantly with mortality (p=0.029).ConclusionA high index of suspicion and prompt recognition of ruptured AAA is of paramount importance. Emergency physicians should familiarise themselves with the clinical presentation and management of patients with ruptured AAA. Emergency ultrasound performed in the AED helps in the early detection of AAA.

383 Contribution of cytological CSF analysis to the management of patients with breast cancer; a retrospective analysis over two decades

Primary aortoenteric fistula (PAEF) is defined as a communication between the native aorta and the gastrointestinal tract, in contrast to secondary fistulas, which arise between a suture line of a vascular graft and the intestine. Arteriosclerosis is the predominant cause of PAEF and accounts for more than two-thirds of the cases reported. The pathogenesis is usually based on direct adhesion of a segment of the gastrointestinal tract to an aortic aneurysm, followed by progressive erosion through the bowel wall. The clinical presentation is usually one of intermittent gastrointestinal haemorrhage resulting in lethal exsanguination. Pain in the abdomen, a pulsatile abdominal mass or fever may be present. The choice of various diagnostic procedures is often decided by the clinical presentation. Esophagogastroduodenoscopy, ultrasound and CT scan may be useful in the evaluation of these patients. Current recommendations for repair include debridement of the aneurysmal aorta, repair with an in situ graft and primary repair of the gastrointestinal tract, followed by aggressive antimicrobial therapy. We present six cases of PAEF surgically treated at the St. Radboud Hospital, the Canisius Wilhelmina Hospital in Nijmegen and the Lukas Hospital in Apeldoorn over a period of 15 years.

Transient Ischemic Attack in an Elderly Patient: What to Expect?

A 77-year-old man presented with an episode of facial droop, confusion, and profuse sweating that resolved en route to the emergency department. A computed tomography scan of the abdomen was ordered when on physical examination a palpable, pulsatile abdominal mass was noted. Computed tomography scan revealed a large infrarenal abdominal aortic aneurysm (AAA) with peripheral thrombus and a small, contained leak (Figure 1).

Anatomical repair of a congenital aneurysm of the distal abdominal aorta in a newborn

Congenital (primary) neonatal abdominal aortic aneurysm (AAA) is an extremely rare truncular arterial abnormality among numerous congenital vascular malformations. Only seven cases have been reported as congenital origin in newborns. This report presents the case of a male infant in whom a 33-mm congenital AAA was diagnosed prenatally and was successfully treated 10 days after birth without exogenous graft material or aneurysmorrhaphy. Follow-up study at 39 months demonstrated excellent clinical, ultrasound scan, and computed tomography scan findings. Anatomic reconstruction with native vessels is the preferred surgical technique to ensure the child's potential for harmonious growth.

Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm with Aortocaval Fistula

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA). We report the endovascular repair of an AAA rupture into the inferior vena cava. A 78-year-old woman was admitted to our hospital for acute hypotension. She presented with a pulsatile abdominal mass and became rapidly anuric. Abdominal computed tomography (CT) showed an AAA rupture into the inferior vena cava. The features of the AAA made it suitable for endovascular repair. To prevent pulmonary embolism caused by the presence of sac thrombosis near the vena cava lumen, a temporary vena cava filter was deployed before the procedure. A bifurcated stent-graft was placed with the patient under local anaesthesia, and the AAA was successfully treated. A transient type II endoleak was detected on CT 3 days after endograft placement. At routine follow-up 6 and 12 months after the procedure, the patient was in good clinical condition, and the type II endoleak had sealed completely. Endovascular treatment offers an attractive therapeutic alternative to open repair in case of ACF; however, only small numbers of patients have been treated, and long-term follow-up interval is lacking.

Bang! The smoker with suprapubic pain

In July, 2006, a 59-year-old man from Macedonia presented with a 6-week history of progressive suprapubic pain. The pain was chronic with sharp episodes, and radiated to the back. He also had loss of appetite, recurrent episodes of nausea, 6 kg weight loss, periods of drenching sweats, and experienced burning sensation when urinating. He was a heavy smoker (80 pack-years). On clinical examination our patient was cachectic, was afebrile, had no lymphadenopathy, but had suprapubic tenderness. Peripheral pulses were normal. Laboratory test results showed normocytic anaemia (haemoglobin 132 g/L) with normal leucocyte and platelet counts, monocytosis (10·3%), and a high concentration of C-reactive protein (36 mg/L). Urinanalysis showed leucocytes and many bacteria. Urinary tract infection was suspected; blood cultures and tests for tuberculosis were done. An abdominal CT was requested, in view of the suspicion of malignancy—the scan showed an infrarenal aortic aneurysm (maximum diameter 3·9 cm) with contrast enhancement in the periaortic tissue (fi gure). The vascular surgeon suspected an infl ammatory process with a high risk of rupture; the patient underwent emergency surgery. Intraoperatively, thickened infl ammatory tissue around the aorta was noted. The infrarenal aorta and aortic bifurcation were completely resected. Because the aortic wall looked normal and intraoperative Gram stains were negative, infl ammatory rather than mycotic pathology seemed most likely. Aortic reconstruction was therefore done with a bifurcated polytetrafl uoroethylene prosthesis. However, histological examination of the aortic wall showed infl ammation of the arterial media with microscopic abscess formation, and severe arteriosclerosis, and brucella species was grown from blood cultures and aortic wall biopsy sample, establishing the diagnosis of mycotic aneurysm. We treated our patient with doxycycline and gentamicin for 14 days followed by rifampicin 900 mg/day and doxycycline 200 mg/day for 6 months. Abdominal CT at 6-month and 12-month follow-up showed no signs of relapse; the prosthesis and intra-abdominal lymph nodes appeared normal, and blood cultures showed no microbial growth during the fi rst 12 months. When last seen in July, 2008, the patient was well. Mycotic aneurysms are an infectious degeneration of the arterial wall, caused either by endocarditis with septic emboli to the vasa vasorum or by direct haematogenous spread during bacteraemia. The term “mycotic” was coined by Osler in 1885 to denote funguslike vegetations; this is misleading, because most cases of mycotic aneurysms are caused by bacteria, most commonly Staphylococcus aureus and salmonella species, although many other pathogens have been implicated. Mycotic aortic aneurysms carry a high risk of rupture and death. The classic clinical signs of fever and a tender pulsatile abdominal mass are often not present or not interpreted correctly. Brucellosis (also known as Bang’s disease) is a worldwide zoonosis and is endemic in the patient’s home country of Macedonia—which he visited regularly. The organism is often transmitted via unpasteurised milk products (typically soft cheese). Bacteraemic spread to the liver, spleen, bones, kidneys, lymph nodes, the reproductive system, or heart valves can occur; mycotic aneurysms, however, are rare. Our patient was managed with a prosthetic graft rather than homograft, autologous veins, or extra-anatomic reconstruction; this approach might be considered controversial. Recurrence rates of up to 10% within a year have been described despite correct antibiotic treatment in the absence of prosthetic material; contaminated prosthetic grafts carry a high risk of recurrence. So far, our patient has had a favourable course, therefore, the prosthetic graft has been left in situ, but further follow-up is essential.

High-output heart failure resulting from a remote traumatic arteriovenous fistula

A 55-year-old man who received a gunshot wound to the right buttock 30 years previously was admitted to the hospital with complaints of progressive exertional dyspnea, nausea, vomiting and right flank pain. On admission, his physical examination demonstrated a blood pressure of 106/73 mmHg, an irregular heart rate of 170 beats/min and an oxygen saturation of 99% on room air. Auscultation revealed bibasilar pulmonary rales and a bruit in the right lower quadrant of the abdomen where palpation demonstrated a tender, pulsatile abdominal mass. Atrial fibrillation with a rapid ventricular response was evident on an electrocardiogram, and an echocardiogram demonstrated new marked biventricular dilation with signs of right ventricular volume overload and a left ventricular ejection fraction of 50%. Subsequent contrast-enhanced computed tomography (CT) scanning revealed cardiomegaly, bilateral pleural effusions, a dilated inferior vena cava and hepatic veins as well as an arteriovenous fistula arising from the right internal iliac artery (RIIA) and communicating with the right common iliac vein (RCIV). There was also evidence of a 12.4 cm × 10.1 cm × 12.3 cm aneurysmal dilation of the RCIV (Figures 1 and ​and2).2). Numerous gunshot pellets were noted throughout the abdomen. Figure 1) Abdominopelvic computed tomography scan demonstrating a 12.4 cm × 10.1 cm × 12.3 cm aneurysmal dilation of the right common iliac vein (RCIV). IVC Inferior vena cava; LCIV Left common iliac vein Figure 2) Abdominopelvic computed tomography scan with three-dimensional reconstruction. IVC Inferior vena cava; RIIA Right internal iliac artery The patient underwent catheterization, at which point, his cardiac output was measured, by the thermodilution method, to be 13.3 L/min. Several percutaneous attempts at exclusion of the RIIA using an Amplatzer vascular plug device (AGA Medical Corporation, USA) as well as several Nester coils (Cook Medical Inc, USA) were unsuccessful. Eventually, the fistula was occluded using a 16 mm Amplatzer atrial septal defect occluder (AGA Medical, USA). Nevertheless, persistent flow from the RIIA into the right internal iliac vein was demonstrated; however, this was expected to diminish as anticoagulation was withdrawn. The patient’s hospital course was further complicated by thrombosis of the venous aneurysm with resultant thrombocytopenia, hematuria and obstructive jaundice. A follow-up angiogram revealed persistent opacification of the fistula from the RIIA. Together with a vascular surgical team, the patient subsequently underwent placement of an endovascular graft converter (Zenith Flex, Cook Medical Inc) in the RIIA (Figure 3) and a permanent inferior vena cava filter (Trapease; Johnson & Johnson, USA) in the RCIV (Figure 4). Although minimal residual flow into the RCIV remained postintervention, it had been reduced significantly by the described interventions. Figure 3) Abdominopelvic computed tomography scan with three-dimensional reconstruction postendovascular graft implantation in the right internal iliac artery Figure 4) Sagittal cut of an abdominopelvic computed tomography scan demonstrating a Trapease filter (Johnson & Johnson, USA) in the inferior vena cava (IVC), the endovascular graft in cross-section and an Amplatzer closure device (AGA Medical Corporation, ... Three weeks after endovascular graft placement, collateral flow from the right L4 lumbar artery into the RIIA was demonstrated by CT angiography with continued opacification of the RCIV from the RIIA. Percutaneous coiling (Diamond Vortex coils; Boston Scientific, USA) of the L4 lumbar artery was then attempted, which resulted in successful exclusion of the RIIA. No further flow into the RIIA could be demonstrated on fluoroscopy. Two weeks later, the patient was pain free and ambulating without complaints of dyspnea. At that time, an echocardiogram demonstrated reduced left and right ventricular dimensions as well as normal biventricular systolic function. A follow-up CT of the patient’s abdomen and pelvis showed a reduction in the size of the aneurysm (9.3 cm × 9.0 cm) as well as absent flow within the fistula and into the RIIA from the L4 lumbar artery. The present case highlights two important points. Previously healthy, young men presenting with high-output congestive heart failure and a history of penetrating injuries to the abdomen and/or pelvis should undergo thorough testing for arteriovenous fistulas. In addition, chronic arteriovenous fistulas often involve complex arteriovenous anatomy, as did our patient, often complicating percutaneous closure. For this reason, meticulous preprocedural evaluation is of the utmost importance. As well, close collaboration between vascular surgery and interventional cardiology/radiology is necessary to facilitate the selection of the most appropriate intervention on a case-by-case basis.

Diagnosis of an ilio-iliac arteriovenous fistula by multidetector row computed tomography and surgical repair

An 82-year-old man presented with typical signs and symptoms of an arteriovenous fistula (AVF) associated with an aortoiliac aneurysm, such as a pulsatile abdominal mass, continuous bruit, thrill, and high output heart failure. Multidetector row computed tomography (MDCT) confirmed the presence of an AVF between the right common iliac artery aneurysm and vein. We subjected the patient to surgical repair of the AVF combined with graft replacement, which proved successful.

Aortocaval Fistula in a Behcet's Disease Patient

Behcet's disease (BD) is a chronic, recurrent, systemic disease that is characterized by oral and genital ulcers and oculocutaneous inflammatory lesions. Cardiovascular involvement especially large artery involvement is a serious and vital complication of BD. Pseudoaneurysms in the major arteries may be the cause of sudden death in BD. In our case a pulsatile abdominal mass was determined to be an aortic pseudoaneurysm associated with BD and an aortocaval fistula. Here we report this case and a short review of literature because this is the first reported aortocaval fistula in a BD patient in English literature.

Case Study: Large Hepatic Artery Aneurysm and a Review of the Literature

Introduction Hepatic artery aneurysm is a rare and life-threatening lesion. Patients with hepatic artery aneurysm are often asymptomatic, which makes diagnosis difficult. Early diagnosis is essential because of the high risk of rupture. The following case describes an incidental finding of a large hepatic artery aneurysm. Methods A 74-year-old woman presented to the vascular lab for a renal artery evaluation. The patient had hypertension and chronic renal failure with elevated blood urea nitrogen and creatinine. Evaluation of the abdominal aorta was also requested because of a palpable, pulsatile abdominal mass and abdominal bruit. The patient additionally stated epigastric and right upper quadrant pain for the previous 6 months. Results The renal arteries displayed normal flow velocities without evidence of stenosis. Bilateral kidneys did exhibit parenchymal disease. Examination of the abdominal aorta demonstrated an infrarenal abdominal aortic aneurysm measuring 6.4 cm. In the proximal abdomen, at the level of the patient's pain, a large 11-cm aneurysm was identified. because of the large size of the aneurysm causing displacement of the vasculature, the artery of origin was not positively identified. To further delineate this lesion, the patient underwent computed tomography and angiography; however, these were also unsuccessful. The patient was eventually brought to the operating room for surgical repair of this aneurysm as well as her infrarenal AAA. Intraoperatively, the aneurysm was found to be originating from the hepatic artery. Conclusion Although a rare finding, hepatic artery aneurysm can be identified and evaluated with ultrasound. Additional testing with computed tomography and angiography helps to define the arterial source and location of the aneurysm, as well as collateral flow to the liver if the hepatic artery is compromised. Once identified, these lesions need to be surgically or interventionally treated due to their high mortality rate.

Staged endourologic and endovascular repair of an infrarenal inflammatory abdominal aortic aneurysm presenting with forniceal rupture

We present the case of a 79-year-old female who presented with severe left flank pain and a pulsatile abdominal mass. She was diagnosed with left peripelvic urinary extravasation and forniceal rupture secondary to an intact infrarenal inflammatory abdominal aortic aneurysm with extensive periaortic fibrosis. Successful operative repair was performed with staged ureteral and endovascular stenting with subsequent resolution of periaortic inflammation and ureteral obstruction, and shrinkage of the aneurysm sac. Inflammatory abdominal aortic aneurysms (IAAAs) represent 5% to 10% of all abdominal aortic aneurysms. The distinguishing features of inflammatory aneurysms include thickening of aneurysm wall, retroperitoneal fibrosis, and adhesions to adjacent retroperitoneal structures. The most commonly involved adjacent structures are the duodenum, left renal vein, and ureter. Adhesions to the urinary system can cause hydronephrosis or hydroureter and result in obstructive uropathy. An unusual case of IAAA presenting with forniceal rupture is presented, with successful endovascular and endourologic repair.

Ruptured aortic aneurysm masquerading as phlegmasia cerulea

Phlegmasia cerulea dolens, characterized by the triad of limb swelling, cyanosis, and acute ischemic pain, usually arises because of acute massive thrombosis of major deep, collateral, and superficial veins of an extremity. We report a patient with an atypically presenting ruptured aortic aneurysm masquerading as phlegmasia cerulea dolens. A 68-year-old man with a history of hypertension, intermittent claudication, and smoking presented with asthenia, macrohematuria, and mild back pain, as well as edema and blue mottling of the lower limbs and abdomen for 24 hours. The abdomen was nontender without a pulsatile mass or murmur. Computed tomography showed an 85-mm abdominal aortic aneurysm ruptured into the inferior vena cava. Phlegmasia cerulea dolens-like symptoms were explained by compromised venous outflow from the lower limbs because of an aortocaval fistula. The patient died of uncontrollable hemorrhage during emergent surgical repair. Three percent to 6% of patients with abdominal aortic aneurysm rupture present an aortocaval fistula, which can be suspected by the triad of abdominal or lower back pain, pulsatile abdominal mass, and machinery-type abdominal murmur. Left untreated, this condition rapidly leads to death from congestive heart failure. Only one third of patients are diagnosed before surgery because a fistula is often not suspected until unexplained massive hemorrhage occurs during the operation. Operative mortality is extremely high (34%). We propose that the clinical syndrome presented by our patient, a "blue fistula" frequently associated with aortocaval fistulae, be called phlegmasia cerulea non dolens, by analogy to Grégoire's "blue phlebitis."

Atypical presentations of ruptured abdominal aortic aneurysm: Case reports

Ruptured abdominal aortic aneurysm (AAA) is an important cause of unheralded deaths in people older than 65 years. The survival of these patients depends on prompt diagnosis with immediate resuscitation and emergency surgery. Hypotension, pulsatile abdominal mass, and flank or back pain, constitute the classic triad for ruptured AAA. However, this triad may be incomplete in as many as 50% of patients. A high index of suspicion is required for prompt treatment of this intra‐abdominal catastrophe. We report three cases of ruptured AAA who presented atypically to our hospital.

A Rare Case of Aortoduodenal Syndrome

Purpose: A 78 yo male with hypertension and CKD presented for evaluation of acute on chronic renal failure. A renal ultrasound incidentally revealed a large 4 cm × 6 cm × 10 cm infra-renal abdominal aortic aneurysm. He was evaluated by vascular surgery who planned an open repair in the near future. 4 days later the patient presented to the emergency department with abdominal pain, nausea and intolerance to po intake. Abdominal exam revealed tenderness, distention and a pulsatile abdominal mass. Significant findings upon work up included hypotension, a creatinine of 5.1 and ST segment changes on EKG. A NG tube was placed which drained 1700 cc fluid with symptomatic improvement. CT showed a proximal duodenum which was obstructed just below the superior mesenteric artery takeoff due to direct compression from the large AAA. The patient underwent cardiac workup for his acute MI. Prior to surgical repair of his AAA he underwent a CABG X 3. Approximately 2 weeks later, after aggressive nutritional support, he successfully underwent an open AAA repair with a tube graft. He is currently in a rehabilitation facility doing well. Methods: Results: Conclusion: Aortoduodenal syndrome is a clinical entity rarely reported in the gastroenterology literature. It was first described in 1905 by William Osler in an article entitled “Aneurysm of the Abdominal aorta.”1 There have been fewer than 30 cases reported in the literature. The AAA compresses the superior mesenteric artery or the transverse segment of the duodenal wall. Patients present with emesis, pulsatile abdominal mass, abdominal pain, weight loss, and electrolyte disturbances.2 The diagnosis should be suspected in a patient with known vascular disease, pulsatile abdominal mass and signs of gastric outlet obstruction. Initial workup should include CT, UGI barium study or EGD to rule out other causes of gastric outlet obstruction. Treatment is initially supportive with attention to nutritional status prior to surgical vascular repair. Osler W. Aneurysm of the abdominal aorta. Lancet 1905;166:1089–96. Deitch J et al. AAA causing duodenal obstruction: 2 case reports and review of the literature. J of Vasc Surg 2004;40:543–7.Figure

Aorto-caval fistula clinically presenting as left renal colic Findings of multislice computed tomography

Spontaneous aorto-caval fistula is a rare complication of abdominal aortic aneurysm. A definitive diagnosis is sometimes difficult, as the classic diagnostic signs (pulsatile abdominal mass with bruit, high-output hearth failure, and acute dyspnea) are present in about half of the patients. Diagnosis may be suspected from clinical symptoms, but sometimes atypical clinical features may obscure the actual situation. Computed tomography findings include early detection of contrast medium in the dilated inferior vena cava, which is isodense with the adjacent aorta, an associated aortic aneurysm, loss of normal anatomic space between aorta and vena cava, and rarely one can even visualize the abnormal communication between aorta and vena cava. Prompt radiological diagnosis is of key importance in the management of these patients. We describe findings of multislice computed tomography of the patient with dissecting aortic aneurysm and aortocaval fistula, clinically presenting as left renal colic. Multislice computed tomography is the imaging modality of choice for diagnosis of abdominal vascular pathology as it is noninvasive, fast and demonstrates a high diagnostic accuracy.

Endovascular treatment of postlaminectomy aortic pseudoaneurysm

Aortic pseudoaneurysm following lumbar laminectomy is a rare but potentially life-threatening complication. We report a case of a 49-year-old female patient who developed a pulsatile abdominal mass and pain following a lumbar laminectomy procedure. An aortic pseudoaneurysm was diagnosed which was successfully treated with endovascular stent-graft exclusion. This report represents the first case of endovascular exclusion of a laminectomy-related aortic pseudoaneurysm. Physicians should be aware of this complication in patients who developed abdominal pulsatile mass with pain following lumbar laminectomy procedure.

Aortic Aneurysms

Abdominal aortic aneurysms (AAAs) cause 1.3% of deaths among men aged 65 to 85 years in developed countries, resulting in approximately 15,000 deaths per year in the United States [ 1 Sakalihasan N. Limet R. Defawe O.D. Abdominal aortic aneurysm. Lancet. 2005; 365: 1577-1589 Abstract Full Text Full Text PDF PubMed Scopus (869) Google Scholar ]. The prevalence of AAAs 3 to 5 cm in diameter is 1.3% in men aged 45 to 54 years and 12.5% in men aged 75 to 84 years. In comparison, the prevalence in women is 0% and 5.2%, respectively [ 2 Hirsch A.T. Haskal Z.J. Hertzer N.R. et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). Circulation. 2006; 113: e463-e654 Crossref PubMed Google Scholar ]. Prevalence varies by race, and AAAs are very rare in Asians [ 2 Hirsch A.T. Haskal Z.J. Hertzer N.R. et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). Circulation. 2006; 113: e463-e654 Crossref PubMed Google Scholar ]. In comparison, thoracic aortic aneurysms (TAAs) cause about 0.01% of deaths, which are equally distributed between women and men [ 3 Svensjo S. Bengtsson H. Bergqvist D. Thoracic and thoracoabdominal aortic aneurysm and dissection: an investigation based on autopsy. Br J Surg. 1996; 83: 68-71 Crossref PubMed Scopus (85) Google Scholar ]. Risk factors that increase the likelihood of aneurysms include family history, smoking, male gender, advancing age, and cardiovascular disease (Table 1) [ 2 Hirsch A.T. Haskal Z.J. Hertzer N.R. et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). Circulation. 2006; 113: e463-e654 Crossref PubMed Google Scholar ]. Table 1Indications for imaging of abdominal aortic aneurysm Screening Men aged ≥65 to 75 years who have ever smoked Men aged ≥60 years with siblings or parents with abdominal aortic aneurysms Women aged ≥65 years with cardiovascular risk factors Men or women aged >50 years with family histories of aneurysmal disease Diagnostic Palpable pulsatile abdominal mass Unexplained lower back or abdominal pain Known aneurysmal disease in extremities Follow-up of previously demonstrated abdominal aortic aneurysm Follow-up of patients with aortic or iliac endoluminal graft Open table in a new tab

Aortocaval Fistula Presenting with Hematuria and Renal Failure

We present a case of a fistula involving the inferior vena cava and an abdominal aortic aneurysm, associated with hematuria and renal failure and which proved fatal. A clinical diagnosis is sometimes difficult because the classic diagnostic signs (pulsatile abdominal mass with bruit, high-output heart failure and low back pain) may be absent in many cases. Nowadays a contrast-enhanced spiral computed tomography scan is usually sufficient to diagnose this pathology.

Tuberculous Spondylitis and Salmonella Mycotic Aneurysm in an Immunocompromised Patient: A Case Report

Despite the proximity of the vertebral bodies and discs to the vascular structures of the retroperitoneum, the association of spinal osteomyelitis and aortic infection is a rare1, easily overlooked, but potentially lethal condition that requires prompt diagnosis and aggressive surgical therapy. The pathogens responsible for concurrent vertebral and aortic lesions include Salmonella species as well as other gram-negative bacilli, mycobacteria, gram-positive cocci, and fungi1-3. A delay in the start of appropriate antimicrobial therapy for infections involving these anatomic sites could result in bone and joint destruction and possibly death. We report the case of an elderly immunocompromised patient who had a mycotic aneurysm caused by Salmonella species. After aneurysmectomy, he experienced persistent back pain and progressive loss of lower-extremity neurological function. Further work up disclosed tuberculous lumbar spondylitis and an epidural abscess in the vicinity of the resected aneurysm. The case of this patient emphasizes the possibility of coexistent infection in vulnerable patients. The pitfalls in diagnosis and management are discussed, to enable clinicians to avoid potentially catastrophic complications. The patient was informed that data concerning the case would be submitted for publication. A seventy-nine-year-old man presented to our emergency service because of fever and chills that he had had for eight days. The history included the use of analgesics and a steroid (20 mg/day of prednisolone) for one year for the treatment of chronic low back pain. On arrival, the patient was febrile (38.4°C), with a blood pressure of 150/90 mm Hg. Physical examination revealed a cushingoid habitus (moon face, truncal obesity, and paper-thin skin), a pulsatile abdominal mass, and low back pain limiting his spinal flexibility. Plain radiographs of the lumbar spine showed multiple traction spurs along the anterior edges of the vertebrae and decreased disc height at L3-L4 without overt evidence …

Iliocaval arteriovenous fistula presenting with multiple organ failure

Iliac arteriovenous fistulas are an uncommon condition, which may be spontaneous or traumatic in nature. Such fistulas classically present with a triad of high-output cardiac failure, pulsatile abdominal mass with a bruit and unilateral leg ischaemia or venous congestion. We describe a case of an iliocaval fistula secondary to rupture of a common iliac artery aneurysm, with an unusual presentation of multiple organ failure, masquerading as sepsis. We describe the CT findings of iliocaval fistula, which was the means of diagnosis in this study.