Signs Of Impending Rupture Research Articles

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES:This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients.METHODS:This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping.RESULTS:From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter.CONCLUSIONS:The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

Acute Blood Products Within the Wall of an Intracranial Aneurysm: A Sign of Impending Rupture.

Acute Blood Products Within the Wall of an Intracranial Aneurysm: A Sign of Impending Rupture.

Right completion pneumonectomy for impending rupture of a pulmonary artery pseudoaneurysm

We present a case of right completion pneumonectomy for a pulmonary artery pseudoaneurysm after right upper lobectomy and radiotherapy for metachronous multiple right lung cancers. An 80-year-old man was referred to our hospital because of repeated hemoptysis. Computed tomography revealed a pseudoaneurysm in an interlobar pulmonary artery. We considered hemoptysis as a sign of impending rupture. Radiologists could not recommend embolization because of a high risk of rupture or pulmonary infarction, and re-hemoptysis due to coil movement; therefore, we performed right completion pneumonectomy because of severe adhesion. At last, the patient has completely recovered from impending rupture status.

Surgical exclusion of a saccular aneurysm within a patent ductus arteriosus in an adult patient with Ortner's syndrome.

In adult the patent ductus arteriosus is a rare condition associated sometimes with lethal complications. We describe the case of a 44-year-old woman with a history of systemic lupus erythematosus admitted to our hospital with hoarseness and severe dyspnea. Clinical imaging examinations indicated a saccular aneurysm within a persistent ductus arteriosus with signs of impending rupture. Patient was not considered suitable for transcatheter closure and therefore she underwent open aortic repair. The procedure was uneventful and any significant complications occurred during postoperative course.

Abdominal aortitis and aneurysm impending rupture during pneumococcal meningitis

A 77-year-old woman presented to our emergency department in Brescia, Italy with fever, altered conscious state, and neck stiff ness. She was a heavy smoker, with hypertension and dyslipidaemia, and had had right-sided back pain for the previous 3 days. Head CT and chest radiograph were normal, whereas lumbar puncture and blood cultures revealed pneumococcal meningitis with bacteraemia. Antibiotic therapy with ceftriaxone (2 g twice daily) was started. The patient rapidly improved, with resolution of fever and substantial reduction of infl ammatory markers (white blood cell count dropped from 19·7 cells per mL to 14·9 cells per mL, and C-reactive protein dropped from 225 mg/L to 108 mg/L). However, 12 days after the patient was admitted to hospital, and less than a week after the initial clinical and biochemical improvement, she reported worsening backache , and the infl ammatory markers rebounded (white blood cell count to 19·8 cells per mL and C-reactive protein to 171 mg/L). Lumbar spine CT showed no signs of spondylodiscitis, but an enlarged abdominal aorta with signs of perianeurysmal infl am mation. The CT angiography done straight afterwards confi rmed the presence of an abdominal aortic aneurysm with signs of impending rupture (fi gure A). Mycotic aneurysm and microbial aortitis are un common entities that usually occur in people with under lying atherosclerotic vascular disease as a consequence of bacteraemic seeding on the abnormal aortic surface. The clinical presentation is often subacute, and the diagnosis often delayed or not made until after death. Streptococcus pneumoniae, despite being a common cause of bacteraemia, is seldom responsible for vascular seeding. Yet, pneumococcal aortitis should be ruled out in patients with sepsis at high risk of cardiovascular diseases presenting with typical symptoms of abdominal aortic aneurysm. The patient promptly underwent aorto-aortic homograft substitution. The patient recovered after surgery without any complications and returned home shortly thereafter. CT angiography done after 1 month, however, revealed the presence of an initial disease progression (fi gure B), but the patient refused any surgery. Since then, she has had strict clinical and radiological follow-up examinations without evidence of further worsening. After almost 12 months she is still alive and in a good clinical condition.

Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer.

An expert panel on the treatment of type B intramural haematoma (IMH) and penetrating atherosclerotic ulcer (PAU) consisting of cardiologists, cardiothoracic surgeons, vascular surgeons and interventional radiologists reviewed the literature to develop treatment algorithms using a consensus method. Data from 46 studies considered relevant were retrieved for a total of 1386 patients consisting of 925 with IMH, and 461 with PAU. The weighted mean 30-day mortality from IMH was 3.9%, 3-year aortic event-related mortality with medical treatment 5.4%, open surgery 23.2% and endovascular therapy 7.1%. In patients with PAU early and 3-year aortic event-mortality rates with open surgery were 15.9 and 25.0%, respectively, and with TEVAR were 7.2 and 10.4%, respectively. According to panel consensus statements, haemodynamic instability, persistent pain, signs of impending rupture and progressive periaortic haemorrhage in two successive imaging studies require immediate surgical or endovascular treatment. In the absence of these complications, medical treatment is warranted, with imaging control at 7 days, 3 and 6 months and annually thereafter. In the chronic phase, aortic diameter >55 mm or a yearly increase ≥ 5 mm should be considered indications for open surgery or thoracic endovascular treatment, with the latter being preferred. In complicated type B aortic PAU and IMH, endovascular repair is the best treatment option in the presence of suitable anatomy.

Rupture signs on computed tomography, treatment, and outcome of abdominal aortic aneurysms.

ObjectivesAbdominal aortic aneurysm (AAA) rupture has a high mortality rate. Although the diagnosis of a ruptured AAA is usually straightforward, detection of impending rupture signs can be more challenging. Early diagnosis of impending AAA rupture can be lifesaving. Furthermore, differentiating between impending and complete rupture has important repercussions on patient management and prognosis. The purpose of this article is to classify and illustrate the entire spectrum of AAA rupture signs and to review current treatment options for ruptured AAAs.MethodsUsing medical illustrations supplemented with computed tomography (CT), this essay showcases the various signs of impending rupture and ruptured AAAs. Endovascular aneurysm repair (EVAR) and open surgical repair are also discussed as treatment options for ruptured AAAs.ResultsCT imaging findings of ruptured AAAs can be categorised according to location: intramural, luminal, and extraluminal. Intramural signs generally indicate impending AAA rupture, whereas luminal and extraluminal signs imply complete rupture. EVAR has emerged as an alternative and possibly less morbid method to treat ruptured AAAs.ConclusionsAAA rupture occurs at the end of a continuum of growth and wall weakening. This review describes the CT imaging findings that may help identify impending rupture prior to complete rupture.Teaching Points AAA rupture occurs at the end of a continuum of growth and wall weakening. Intramural imaging findings indicate impending AAA rupture. Luminal and extraluminal imaging findings imply complete AAA rupture. Some imaging findings are not specific to AAA ruptures and can be seen in other pathologies. EVAR has emerged as an alternative and possibly less morbid method of treating ruptured AAAs.

Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

From the Department of Radiology, Division of Vascular Imaging and Intervention (T.G.W., S.P.K., K.Y., S.W.), Massachusetts General Hospital, Boston, Massachusetts; Department of Medical Imaging (S.K.), Scarborough General Hospital, Toronto, Ontario, Canada; Department of Interventional Radiology (P.D.), West Allis Memorial Hospital, Milwaukee, Wisconsin; Department of Radiology, Division of Interventional Radiology (B.J.D.), University of Maryland Medical Center, Baltimore, Maryland; Department of Radiology (S.C.R.), University of California San Diego Medical Center, San Diego, California; and Department of Radiology (J.F.C.), Geisinger Health System, Danville, Pennsylvania. Received May 4, 2010; final revision received May 24, 2010; accepted July 11, 2010. Address corre-

Can computed tomography scan findings predict “impending” aneurysm rupture?

Conclusion: Computed tomography (CT) signs of “impending rupture” are poor predictors of short-term aortic aneurysm rupture. Summary: A number of signs that are present on CT scans have been advocated in the radiologic literature as indicating increased risk of rupture of abdominal aortic aneurysms and have been suggested to indicate “imminent” or “impending” aneurysm rupture (AJR 1994;163:1123-9). These signs include the “crescent sign,” a curvilinear area of higher attenuation within the aneurysm that may represent hemorrhage into mural thrombus; ill defined or irregular aortic walls, discontinuity of circumaortic calcification, aortic bulges or blebs, and draping of the aorta over the spine. This study reviewed a medical records system from August 1994 to August 2004 looking for CT scan reports of impending rupture. Medical records were also reviewed for patient demographics, symptoms, comorbidities, and documented subsequent aneurysm rupture, operative findings, or both. If a rupture occurred ≤2 weeks of the index CT scan, it was defined as supporting the imminent rupture diagnosis. The record retrieval system identified 45 patients with aortic aneurysms and CT stigmata of impending rupture. Six patients were excluded because five had additional signs suspicious for leak and another had a previously repaired aneurysm and associated infection. Therefore, 39 intact aneurysms were evaluated, of which 26 (67%) were infrarenal, two (5%) were suprarenal, and 11 (28%) were thoracoabdominal. Mean aneurysm diameter was 6.8 ± 1.4 cm. Mean patient age was 74 years, and 49% were women. Ten patients underwent elective repair during the first 2 weeks that precluded adequate observation for early rupture. None of these patients had intraoperative signs of rupture. Two of the remaining 29 patients suitable for more long-term evaluation ruptured ≤72 hours of the CT scan. The positive predictive value of the diagnosis of impending rupture was therefore 6.9%. One other patient’s aneurysm ruptured 7 months after the initial CT scan. Twenty-six patients whose aneurysms did not rupture were observed over an average length of follow-up of 246 days (range, 14 days to 3 years). Of these patients, 14 were repaired electively 2 to 3 weeks after the CT scan, and 12 never underwent repair. These 12 were observed for a mean of 394 days without rupture. Comment: Every vascular surgeon will at one time be faced with the dilemma of what to do with a patient with a large abdominal aortic aneurysm and a radiologic diagnosis of impending rupture without clear evidence of leakage from the aneurysm. Since the risk of acute rupture in these patients seems quite low, the authors’ data suggest that an approach of expedient but not emergent operation is reasonable. Nevertheless, the weaknesses of these data are obvious in that only patients who had a diagnosis of impending rupture included in their official CT report were in the database. The data would have been more complete if the authors had also evaluated all patients with aortic aneurysm rupture and a previous CT scan. Perhaps some of these patients had signs of impending rupture that were not included in the official radiologic report.

Can computed tomography scan findings predict “impending” aneurysm rupture?

Conclusion: Computed tomography (CT) signs of “impending rupture” are poor predictors of short-term aortic aneurysm rupture. Summary: A number of signs that are present on CT scans have been advocated in the radiologic literature as indicating increased risk of rupture of abdominal aortic aneurysms and have been suggested to indicate “imminent” or “impending” aneurysm rupture (AJR 1994;163:1123-9). These signs include the “crescent sign,” a curvilinear area of higher attenuation within the aneurysm that may represent hemorrhage into mural thrombus; ill defined or irregular aortic walls, discontinuity of circumaortic calcification, aortic bulges or blebs, and draping of the aorta over the spine. This study reviewed a medical records system from August 1994 to August 2004 looking for CT scan reports of impending rupture. Medical records were also reviewed for patient demographics, symptoms, comorbidities, and documented subsequent aneurysm rupture, operative findings, or both. If a rupture occurred ≤2 weeks of the index CT scan, it was defined as supporting the imminent rupture diagnosis. The record retrieval system identified 45 patients with aortic aneurysms and CT stigmata of impending rupture. Six patients were excluded because five had additional signs suspicious for leak and another had a previously repaired aneurysm and associated infection. Therefore, 39 intact aneurysms were evaluated, of which 26 (67%) were infrarenal, two (5%) were suprarenal, and 11 (28%) were thoracoabdominal. Mean aneurysm diameter was 6.8 ± 1.4 cm. Mean patient age was 74 years, and 49% were women. Ten patients underwent elective repair during the first 2 weeks that precluded adequate observation for early rupture. None of these patients had intraoperative signs of rupture. Two of the remaining 29 patients suitable for more long-term evaluation ruptured ≤72 hours after the CT scan. The positive predictive value of the diagnosis of impending rupture was therefore 6.9%. One other patient’s aneurysm ruptured 7 months after the initial CT scan. Twenty-six patients whose aneurysms did not rupture were observed over an average length of follow-up of 246 days (range, 14 days to 3 years). Of these patients, 14 were repaired electively 2 to 3 weeks after the CT scan, and 12 never underwent repair. These 12 were observed for a mean of 394 days without rupture. Comment: Every vascular surgeon will at one time be faced with the dilemma of what to do with a patient with a large abdominal aortic aneurysm and a radiologic diagnosis of impending rupture without clear evidence of leakage from the aneurysm. Since the risk of acute rupture in these patients seems quite low, the authors’ data suggest that an approach of expedient but not emergent operation is reasonable. Nevertheless, the weaknesses of these data are obvious in that only patients who had a diagnosis of impending rupture included in their official CT report were in the database. The data would have been more complete if the authors had also evaluated all patients with aortic aneurysm rupture and a previous CT scan. Perhaps some of these patients had signs of impending rupture that were not included in the official radiologic report.

Causes and prevention of carotid artery rupture

Rupture of the carotid arteries, which provide blood supply to the head and neck, results in massive haemorrhage leading to death within a matter of minutes in 33% of cases. Those who survive are frequently left handicapped. Patients with head and neck cancer who are over 50 years of age with excessive weight loss and reduced haemoglobin, have a greater risk of carotid artery damage leading to rupture, as have those with existing nutritional deficiencies, cardiovascular or renal disease, or endocrine disorders. Prevention includes improving the nutritional status, preventing infection and constipation, promoting healing and using safe suctioning. The signs of impending rupture are few and include: retro-sternal or high epigastric pain, pulsation of the wound, ballooning of the artery and, occasionally, a small 'herald' bleed. Nurses need to be aware of 'at risk' patients, and the warning signs. All ear, nose and throat wards should document an evidence-based protocol for the management of carotid artery rupture.

Traumatic rupture of the thoracic aorta: Ten years of delayed management

Traumatic rupture of the thoracic aorta is a highly fatal condition in which patient outcome is strongly conditioned by other associated injuries. Delayed aortic treatment has been proposed to improve results. The charts of 69 patients with traumatic rupture of the thoracic aorta observed between 1980 and 2003 were reviewed. Patients were grouped according the timing of repair: group I, immediate repair (21 patients); and group II, delayed repair (48 patients). In group II, 45 patients were treated surgically or by endovascular procedure. In-hospital mortalities were 4 of 21 patients (19%) in group I and 2 of 48 patients (4.2%) in group II. There were 3 cases of paraplegia in group I and none in group II. Improvement of patient outcome with traumatic rupture of the thoracic aorta can be achieved by delaying surgical repair until after management of major associated injuries if there are no signs of impending rupture. Endovascular treatment is feasible and safe and may represent a valid alternative to open surgery in selected cases.

Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept.

Penetrating atherosclerotic ulcer is an ulcerating atherosclerotic lesion that penetrates the elastic lamina and is associated with hematoma formation within the media of the aortic wall. This pathologic condition is distinct from classic aortic dissection and aortic rupture; however, care should be taken in making the diagnosis, particularly if the disease is discovered incidentally. At computed tomography (CT), penetrating atherosclerotic ulcer manifests as focal involvement with adjacent subintimal hematoma and is often associated with aortic wall thickening or enhancement. Magnetic resonance imaging is superior to conventional CT in differentiating acute intramural hematoma from atherosclerotic plaque and chronic intraluminal thrombus and allows unenhanced multiplanar imaging. Spiral CT involves shorter examination times and allows high-quality two- and three-dimensional image reconstruction. CT angiography can demonstrate complex spatial relationships, mural abnormalities, and extraluminal pathologic conditions. Transesophageal echocardiography has been reported to be highly sensitive and specific in the differentiation of aortic disease, and intravascular ultrasonography may also be useful in this setting. Although rupture or other life-threatening complications are rare, patients with penetrating atherosclerotic ulcer must be followed up, particularly during the 1st month after onset. Surgical treatment may become necessary in cases involving evidence of intramural hematoma expansion, signs of impending rupture, inability to control pain, or blood pressure changes.

Are We Able to Prevent Death Due to Postinfarction Cardiac Rupture by Early Diagnosis and Surgical Treatment?

Death from postinfarction cardiac rupture (PCR) may occur in two ways. There are patients who die suddenly without symptoms or with symptoms of less than an hour's duration (sudden cardiac death), whereas other patients die several hours after the onset of the rupture. Ninety-six patients who died from AMI and underwent autopsy have been studied. Sixteen patients displayed a rupture of the free wall of the left ventricle at the site of infarction, cardiac hypertrophy and severe coronary alterations. Six of these patients were included among patients who died suddenly. The other 10 showed signs before death that occurred from 240 to 660 min after their appearance. Signs of impending rupture were appearance or increase of chest pain that was not improved by opiates, preterminal sinus rhythm with an unchanged ST-segment and echocardiographic infarct expansion or pericardial effusion. We propose that the emergence of these signs during AMI suggests an impending rupture. Early surgical intervention is essential to save those patients who survive several hours after the initial signs of PCR.