As the global population ages, the issue of abdominal aortic aneurysm continues to grow. With the evolution of new devices and refined operative technique, aneurysm treatment via endovascular aortic repair is becoming increasingly favourable. This, however, is not without drawbacks, where regular surveillance is paramount to long-term success and detection of post-procedure complications. Of these complications, endoleak is the most notable and poses the greatest risk of potential future aortic rupture. The purpose of this review paper is to discuss the armada of imaging modalities used in the detection and evaluation of endoleak and their varying usefulness. Plain abdominal X-ray is a cost-effective tool in detecting gross graft abnormalities such as stent migration or deformity (kinking or fracture). Though it may raise suspicion for endoleak, X-ray does not allow accurate classification of endoleak type when used alone. Duplex ultrasonography quantifies both aortic anatomy and real time flow dynamics. Most screening programmes are conducted using two-dimensional ultrasound. Unfortunately, observer and equipment variability may lead to surveillance discrepancies-but reduced when utilising a dedicated vascular sonography laboratory. Contrast enhanced ultrasonography is a promising alternative to computed tomography, though still is emerging. Computed tomography angiography certainly has disadvantages (ionising radiation, contrast-nephropathy, limited differentiation of endoleak type)-however, it provides near-real surgical dimensions and highlights graft complications and concomitant disease (such as neighbouring infection). With widespread availability and short scan time, it certainly remains valuable in surveillance. Magnetic resonance angiography has a similar sensitivity to computed tomography (minus the radiation), however is plagued by movement and metal artefact. Other novel modalities in endoleak surveillance include fourdimensional ultrasound, multiplanar intra-operative probes, nuclear medicine and wall stress analysis.
Mycotic infrarenal aortic aneurysms are rare and often masquerade as other abdominal pathology. We present a case where serial imaging made the diagnosis and provided an insight into the pathophysiology of mycotic aneurysm. A 71-year-old man presents with abdominal pain, rigours and dysuria. Computed tomography reveals an irregular, thickened ectatic abdominal aorta, but cholescintigraphy suggests acalculous cholecystitis. Deterioration prompts repeat radiographical assessment, which demonstrates an increase in the size of the aorta over 10 days. The patient was treated emergently with an open aortic ligation, debridement and extra-anatomical bypass. Infections account for up to 2% of abdominal aortic aneurysms. The rate of growth of mycotic aneurysms is sparsely discussed in the literature and to our knowledge, there are no reports with serial single-modality imaging. The most significant finding was rapid expansion in aneurysm size. While mycotic aneurysm requires urgent treatment, diagnosis can be delayed and difficult.
We present a case of intramural duodenal haematoma caused by inferior vena caval (IVC) filter strut perforation requiring innovative open and endovascular retrieval. A 32-year-old woman presents in shock with dull epigastric pain and non-bilious vomiting. She had previously had an IVC filter for deep venous thrombosis and pulmonary embolism. Computed tomography demonstrated strut perforation into the second part of the duodenum, causing intramural haematoma and duodenal obstruction. Laparotomy facilitated evacuation of the duodenal haematoma, while the IVC filter was retrieved by endovascular means. Causes of duodenal haematoma include blunt trauma, haematologic malignancy, coagulopathy, percutaneous or endoscopic procedures, pancreatic pathology, peptic ulcer disease and aortoenteric fistula. Duodenal haematoma is rare and is usually managed conservatively or by percutaneous drainage. While this patient had a typical presentation, IVC filter strut perforation has not been described in the literature as a cause for duodenal haematoma.
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