A male patient, 69 years old, presented with

fever, leucocytosis, and persistent low back pain; he also

had an abdominal aortic aneurysm (AAA), as previously

diagnosed by Doppler UltraSound (US), and was admitted

to our hospital. On multislice computed tomography

(msCT), a large abdominal mass having no definite border

and involving the aorta and both of the psoas muscles was

seen. This mass involved the forth-lumbar vertebra with

lysis, thus simulating AAA rupture into a paraspinal collection;

it was initially considered a paraspinal abscess.

After magnetic resonance imaging examination and culture

of the fluid aspirated from the mass, no infective organisms

were found; therefore, a diagnosisof chronically contained

AAA rupture was made, and an aortic endoprosthesis was

subsequently implanted. The patient was discharged with

decreased lumbar pain. At 12-month follow-up, no evidence

of leakage was observed. To our knowledge, this is

the first case of endoprosthesis implantation in a patient,

who was a poor candidate for surgical intervention due to

renal failure, leucocytosis and high fever, having a chronically

contained AAA ruptured simulatingspodilodiscitis

abscess. Appropriate diagnosis and therapy resolved

potentially crippling pathology and avoided surgical graftrelated

complications.

Keywords Abdominal aortic aneurysm  

Endoprosthesis implantation   Vertebral erosio

Chiocchi,M

Gandini,R

Maresca,L

Messina,M

Pipitone,V

Simonetti,G

A male patient, 69 years old, presented with
fever, leucocytosis, and persistent low back pain; he also
had an abdominal aortic aneurysm (AAA), as previously
diagnosed by Doppler UltraSound (US), and was admitted
to our hospital. On multislice computed tomography
(msCT), a large abdominal mass having no definite border
and involving the aorta and both of the psoas muscles was
seen. This mass involved the forth-lumbar vertebra with
lysis, thus simulating AAA rupture into a paraspinal collection;
it was initially considered a paraspinal abscess.
After magnetic resonance imaging examination and culture
of the fluid aspirated from the mass, no infective organisms
were found; therefore, a diagnosisof chronically contained
AAA rupture was made, and an aortic endoprosthesis was
subsequently implanted. The patient was discharged with
decreased lumbar pain. At 12-month follow-up, no evidence
of leakage was observed. To our knowledge, this is
the first case of endoprosthesis implantation in a patient,
who was a poor candidate for surgical intervention due to
renal failure, leucocytosis and high fever, having a chronically
contained AAA ruptured simulatingspodilodiscitis
abscess. Appropriate diagnosis and therapy resolved
potentially crippling pathology and avoided surgical graftrelated
complications.
Keywords Abdominal aortic aneurysm  
Endoprosthesis implantation   Vertebral erosio

GANDINI, ROBERTO

SIMONETTI, GIOVANNI MARIA EGISTO

CASE REPORTChronic Contained Rupture of an Abdominal Aortic Aneurysm:From Diagnosis to Endovascular ResolutionRoberto Gandini Æ Marcello Chiocchi Æ Luciano Maresca Æ Vincenzo Pipitone ÆMassimo Messina Æ Giovanni SimonettiReceived: 28 January 2007 / Accepted: 25 July 2007 / Published online: 21 August 2007 Springer Science+Business Media, LLC 2007Abstract A male patient, 69 years old, presented withfever, leucocytosis, and persistent low back pain; he alsohad an abdominal aortic aneurysm (AAA), as previouslydiagnosed by Doppler UltraSound (US), and was admittedto our hospital. On multislice computed tomography(msCT), a large abdominal mass having no definite borderand involving the aorta and both of the psoas muscles wasseen. This mass involved the forth-lumbar vertebra withlysis, thus simulating AAA rupture into a paraspinal col-lection; it was initially considered a paraspinal abscess.After magnetic resonance imaging examination and cultureof the fluid aspirated from the mass, no infective organismswere found; therefore, a diagnosisof chronically containedAAA rupture was made, and an aortic endoprosthesis wassubsequently implanted. The patient was discharged withdecreased lumbar pain. At 12-month follow-up, no evi-dence of leakage was observed. To our knowledge, this isthe first case of endoprosthesis implantation in a patient,who was a poor candidate for surgical intervention due torenal failure, leucocytosis and high fever, having a chron-ically contained AAA ruptured simulatingspodilodiscitisabscess. Appropriate diagnosis and therapy resolvedpotentially crippling pathology and avoided surgical graft-related complications.Keywords Abdominal aortic aneurysm Endoprosthesis implantation  Vertebral erosionLumbar pain is a nonspecific sign of disease. Among thefactors that determine its onset, the presence of a chronicbroken aneurysm is an uncommon but valid indication forsurgery. Choplin et al. [l] described a ruptured abdominalaortic aneurysm (AAA) simulating pyogenic vertebralspondylitis with vertebral erosion in 1982. Others investi-gators [2–5] reported chronically contained AAA ruptureas early as 1986. In our case, Multislice computedtomography (msCT) and magnetic resonance imaging(MRI) helped differentiate the cause of the vertebral lysisas a chronically contained AAA rupture rather than oste-omyelitis. Diagnostic imaging, integrated withendovascular approach, correctly identified this pathologyand allowed us to resolve it in a less-invasive manner.Case ReportA 69-year-old man with a 3-year clinical history of end-stage renal failure and dialysis and an AAA, as previouslydiagnosed by Doppler UltraSound (US), located below theorigin of the renal artery. He presented at our hospital withfever (38.5C, duration 1 week), leucocytosis (12,000/fll),persistent low back pain transmitted to the left gluteus-crural region that did not respond to corticosteroids andnonsteroidal anti-inflammatory drugs.A msCT scan was performed (Light Speed Plus [4rows]; General Electric) (Fig. 1) to exclude aneurismalfissuration; this confirmed an AAA (7 cm in diameter)located just 1.5 cm below the renal arteries and extendingto the iliac bifurcation. Apparent maximum diameter of thelesion reached [17 cm because of its extension along theR. Gandini  M. Chiocchi  L. Maresca  V. Pipitone M. Messina  G. SimonettiDepartment of Diagnostic and Molecular Imaging,Interventional Radiology, Nuclear Medicine and RadiationTherapy, University of Rome ‘‘Tor Vergata, 81 Oxford Street,Rome 00133, ItalyR. Gandini (&)Department of Radiology, University of Rome ‘‘ Tor Vergata ,’’,81 Oxford street, Rome 00133, Italye-mail: marcello.chiocchi@fastwebnet.it123Cardiovasc Intervent Radiol (2008) 31:S62–S66DOI 10.1007/s00270-007-9154-yparavertebral spaces into a mass with soft-tissue density.This mass, extending to the common iliac arteries, pre-sented intralesional air bubbles and a thick, calcifiedperipheral ring and infiltrated the ileo-psoas muscles, withlysis of the fourth lumbar vertebra. No narrowing of thespinal canal was present.This msCT finding, because of the presence of bothintralesional air with a ring enhancement and extensioninto the left pelvis, showed what was suspected to be os-teomyelytic spondylolysis with paraspinal abscess that hadprobably fistulised into the aorta.To confirm the presence of nerve involvement andensure the inflammatory origin of the mass, magnetic res-onance angiogram (MRA) (1.5T Achieva Philips MedicalSystem; Best, The Netherlands) was performed by meansof spiral sagittal TI-T2–weighted coronal gradient-echo(GE) sequences and axial and sagittal contrast-enhancedT1-weighted sequences.The lesion showed central isointense and peripheralhyperintense signals compared with muscle intensity on Tl-weighted images, and it showed central hyperintensity andperipheral heterogeneous signal intensity on T2-weightedimages. No enhancement was detected in or around thelesion.Signal intensity alteration of L4, with lytic aspect of thesoma and poor discal involvement, were noted (Figs. 2Aand 2B). Because there was no discernible plane betweenthe dilated aorta and the mass, it was thought to be apseudo aneurysm of the aorta eroding into the vertebra;moreover, the results of msCT-guided needle aspirationusing a 19G 20-cm needle with a 5F (outer diameter)sheath (TLA needle sheath; Boston Scientific, Watertown,MA) in the site of the psoas fluid collection demonstrateddense, brown fluid with some particles of blood clot, but nopathologic organisms grew on cultures.After conferring with the vascular surgeon and anaes-thesiologist, it was decided to perform endovascularexclusion of the aneurysm. Radiologists planned the en-dovascular treatment and the choice of type and dimensionof the device based on msCT findings and intraproceduralangiography.A team of two vascular surgeons and two interventionalradiologists performed the procedure in an Angio-Suite(ARC X12; Philips Medical Systems, Best, The Nether-lands). Surgical exposure of both femoral arteries andplacement of an aortic endoprosthesis (main body 28-mmdiameter, iliac segments 14.5 mm, and length 16 cm[Excluder; Gore, Flagstaff, AZ]) was accomplished usingthe left femoral approach, and left hypogastric artery em-bolisation with five Gianturco coils (Cook, Bloomington,IN) was carried out by the interventional radiologists. Acontralateral endoprosthesis (proximal diameter 16 mm,distal diameter l4 mm, and length 12 cm) plus an aorticextender (diameter 23 mm and length 3.3 cm) (Excluder)was subsequently positioned in the aneurysmatic right iliacartery. Postprocedural angiography showed exclusion ofthe aneurysmatic sac, and despite the patient’s renal failure,Fig. 1 Abdominal multislice computed tomography (msCT) msCTimage shows an infrarenal AAA rupture with vertebral body erosionFig. 2 (A) T1-weighted/TSE (Turbo Spin Echo) sagittal (TE 12, TR682) and (B) T2-weighted/FFE (Fast Field Echo) sagittal (TE 9.2, TR450) MRI images of the lumbar spine shows a large defect in thefourth lumbar vertebrae. The anterior margins of the vertebrae arecompletely eroded by what appears to be a predominantly preverte-bral mass. The posterior margin of the aorta is not well depicted onthese sequencesR. Gandini et al.: Chronic Contained Rupture of an Abdominal Aortic Aneurysm S63123there was preservation of renal artery patency and no in-traprocedural complications.Antibiotic therapy with amoxicillin (2 g/d) was admin-istrated 1 day previous to and for 5 days after theintervention. Postprocedural therapy was adopted only inthis case cause of patient’ leucocytosis. The patient wasdischarged 11 days after in hospital admission withdecreased lumbar pain, most of which could be managedwith nonsteroidal anti-inflammatory drugs.No pathologic organisms or infection were noted at thetime of the patient’s discharge (leucocytes 8000/fll). At 1-,6-, and 12-month follow-up (Fig. 3), preferred msCTcolor-Doppler UltraSound and to other x-ray exams, noevidence of leakage nor increase or decrease of the an-eurismal diameter was observed; however, the patient stillhad some residual back pain, caused by excessive boneloss, that was not solvable with vertebroplasty.DiscussionRupture of an AAA is a surgical emergency with a mor-tality rate, if untreated, of 90% at 6 weeks and an operativemortality rate of 30% to 60% [6–9]. In patients withouthypertension [1, 10–12], a sealed aneurism could occur,without any significant change in blood values because ofrestricted blood loss. These patients are often clinicallystable for prolonged periods and are defined as having achronically contained rupture (also termed ‘‘sealed,’’‘‘spontaneously healed,’’ or ‘‘leaking’’) of the AAA [2, 3,13].Sealed rupture of an AAA causing vertebral erosion israre, and on review of the literature, we found only a fewsuch cases [1, 4, 5, 10, 11, 14, 15]. All patients had normalor high blood pressure, and they were hemodynamicallystable at initial presentation. The most common presentingsymptom was back pain; the duration of symptoms rangedfrom 2 weeks to 2 years. The mechanism of chronicallycontained AAA rupture is not clear. It is believed that inlarge aneurysms, a strong perianeurysmal reaction subse-quently provides high resistance to extravasation of blood[13].Moreover, the site of sealed AAA rupture has beenreported as posterior in 62.5% of cases, suggesting thatvertebrae can tamponade the rupture effectively because oftheir inherent strength [13]; transmitted arterial pulsationand vertebral compression of 80 to 90 times/min mayproduce extensive bone destruction with time [13],involving nerve roots or fibers that pass around muscles [7,15–17]. Erosion caused by aneurysms is usually smoothcompared with that caused by pyogenic infection, in whichthe margins of the lytic process are irregular and poorlydefined [3, 18].msCT and MRI are fundamental to accurate and timelydiagnosis. They are necessary to assess adequate interven-tion to avoid rupture into the intraperitoneal orFig. 3 Abdominal multislice spiral CAT. Abdominal CAT showstotal exclusion of the aneurysmatic sac after positioning of theendoprosthesisFig. 4 T1-weighted/FFE/MIP (Maximum Intensity Projection) coro-nal (TE 1.3, TR 17) MRI images. Angio-MRI coronal-MIP shows alarge infrarenal AAA extending to the left and right common iliacarteriesS64 R. Gandini et al.: Chronic Contained Rupture of an Abdominal Aortic Aneurysm123retroperitoneal cavity and the surrounding hollow structures(e.g., veins and bowel). Diagnostic imaging can also be usedto accurately distinguish abdominal or back pain attributableto ruptured AAA from other causes [14, 17–23].Our case report demonstrates how appropriate diagnosisand therapy can resolve crippling pathology and avoidsurgical graft-related complications, such as pseudoaneu-rysm or haemorrhage at the anastomotic site, graftthrombosis, atheroembolism or infection, graft-entericerosion, and colon ischaemia. A complication rate of 9.4%,especially in a patient such as ours, who was a poor can-didate for surgery, has been reported [9, 14, 22].msCT or MRA, integrated with endovascular therapy,provides an invaluable, less-invasive means by which todepict and exclude the aneurysmal sac; provides promptrepair of this dangerous pathology, which is difficult toidentify; and re-establishes an acceptable quality of life forthe patient.To our knowledge, this is the first case of endoprosthesisimplantation in a patient, who was a poor candidate forsurgical intervention, with chronically contained AAArupture simulating a spodilodiscitis abscess.References1. Choplin RH, Karstaedt N, Wolfman NT (1982) Rupturedabdominal aortic aneurysm simulating pyogenic vertebral spon-dylitis. AJR Am J Roentgenol 138:748–7502. Rosenthal D, Clark MD, Stanton PE, et al. (1986) ‘‘Chronic-contained’’ ruptured abdominal aortic aneurysm: Is it real? JCardiovasc Surg (Torino) 27:723–7243. Jones CS, Reilly KM, Dalsing MC, et al. (1986) Chronic con-tained rupture of abdominal aortic aneurysm. Arch Surg121:542–5454. Bansal M, Bansal M, Thukral BB, et al. (2006) Contained ruptureof a thoracoabdominal aortic aneurysm presenting as a backmass. J Thorac Imaging 21(3):219–2215. Saiki M, Urata Y, Katoh I, et al. (2006) Chronic contained rup-ture of an abdominal aortic aneurysm with vertebral erosion:Report of a case [review]. Ann Thorac Cardiovasc Surg12(4):300–3026. Gavant ML, Salazar JE, Ellis J (1986) Case report. Intrarenalrupture of the abdominal aorta: CT features. J Comput AssistTomogr 4:529–5327. Darling RC (1970) Ruptured arteriosclerotic abdominal aorticaneurysms. A pathologic and clinical study. Am J Surg 119:402–4078. Dillon M, Cardwell C, Blair PH, et al. (2007) Endovasculartreatment for ruptured abdominal aortic aneurysm [review].Cochrane Database Syst Rev 24(1):CD0052619. Biancari F, Ylonen K, Anttila V, Juvonen J, Romsi P, Satta J,et al. (2002) Durability of open repair of infrarenal abdominalaortic aneurysm: A 15-year follow-up study. J Vasc Surg35(1):87–9310. Prete PE, Thorne RP, Robinson CA (1980) Low-back pain andvertebral erosion due to aortic anastomotic false aneurysm, withdocumentation by computerized tomography: A case report. JBone Joint Surg Am 62:126–12811. Galessiere PF, Downs AR, Greenberg HM (1994) Chronic,contained rupture of aortic aneurysms associated with vertebralerosion. Can J Surg 37:23–2812. Szilagyi DE (1982) Clinical diagnosis of intact and rupturedabdominal aortic aneurysms. In: Bergan JJ, Yao JST (eds)Aneurysms: Diagnosis and treatment. New York, NY, Grune &Stratton, pp 205–21613. Sterpetti AV, Blair EA, Schultz RD, et al. (1990) Sealed ruptureof abdominal aortic aneurysms. J Vasc Surg 11:430–435Fig. 5 Diagnostic angiography with centimetred pig-tail confirmed alarge infrarenal AAA with a proximal neck 1.5 cm in lengthFig. 6 Angiography after position of the endoprosthesis demon-strates complete exclusion of the aneurysmatic sacR. Gandini et al.: Chronic Contained Rupture of an Abdominal Aortic Aneurysm S6512314. Kapoor V, Kanal E, Fukui MB (2001) Vertebral mass resultingfrom a chronic-contained rupture of an abdominal aorticaneurysm repair graft. AJNR Am J Neuroradiol 22(9):1775–177715. Defraigne JO, Sakalihasan N, Lavigne JP, et al. (2001) Chronicrupture of abdominal aortic aneurysm manifesting as cruralneuropathy [review]. Ann Vasc Surg 15(3):405–41116. Higgins R, Peitzman AB, Reidy M, et al. (1998) Chronic con-tained rupture of an abdominal aortic aneurysm presenting as alower extremity neuropathy. Ann Emerg Med 17:284–28717. Ando M, Igari T, Yokoyama H, et al. (2003) CT features ofchronic contained rupture of an abdominal aortic aneurysm. AnnThorac Cardiovasc Surg 9:274–27818. Jacquot JM, Strubel D, Joyeux A, et al. (1996) Sealed rupture ofan abdominal aortic aneurysm with chronic vertebral destructionas the first manifestation. Contribution of computed tomographyto the diagnosis. Rev Rhum Engl Ed 63(5):377–37919. William LR, Flinn WR, Yao JST (1985) Extended use of com-puted tomography in the management of complex aortic problem:a learning experience. J Vasc Surg 4:264–27120. Senapatti A, Hurst PAE, Thomas IL (1986) Differentiation ofruptured aortic aneurysm from acute expansion by computerizedtomography. J Cardiovasc Surg (Torino) 27:719–72221. Johnson WC, Gale ME, Gerzol SG (1986) The role of computedtomography in symptomatic aortic aneurysms. Surg GynecolObstet 162:49–5322. Hallet JW Jr, Marshall DM, Petterson TM, et al. (1997) Graft-related complications after abdominal aortic aneurysm repair:Reassurance from a 36-year population-based experience. J VascSurg 25:277–28623. Schwartz SA, Taljanovic MS, Smyth S, et al. (2007) CT findingsof rupture, impending rupture, and contained rupture of abdom-inal aortic aneurysms [review]. AJR Am J Roentgenol188(1):W57-W62S66 R. Gandini et al.: Chronic Contained Rupture of an Abdominal Aortic Aneurysm123

English

Chronic Contained Rupture of an Abdominal Aortic Aneurysm: From Diagnosis to Endovascular Resolution

Gandini, R

Chiocchi, M

Maresca, L

Pipitone, V

Messina, M

Simonetti, G

Cineca Institutional Research Information System

Archivio della Ricerca - Università di Roma Tor vergata

CASE REPORT
Chronic Contained Rupture of an Abdominal Aortic Aneurysm:
From Diagnosis to Endovascular Resolution
Roberto Gandini Æ Marcello Chiocchi Æ Luciano Maresca Æ Vincenzo Pipitone Æ
Massimo Messina Æ Giovanni Simonetti
Received: 28 January 2007 / Accepted: 25 July 2007 / Published online: 21 August 2007
 Springer Science+Business Media, LLC 2007
Abstract A male patient, 69 years old, presented with
fever, leucocytosis, and persistent low back pain; he also
had an abdominal aortic aneurysm (AAA), as previously
diagnosed by Doppler UltraSound (US), and was admitted
to our hospital. On multislice computed tomography
(msCT), a large abdominal mass having no definite border
and involving the aorta and both of the psoas muscles was
seen. This mass involved the forth-lumbar vertebra with
lysis, thus simulating AAA rupture into a paraspinal col-
lection; it was initially considered a paraspinal abscess.
After magnetic resonance imaging examination and culture
of the fluid aspirated from the mass, no infective organisms
were found; therefore, a diagnosisof chronically contained
AAA rupture was made, and an aortic endoprosthesis was
subsequently implanted. The patient was discharged with
decreased lumbar pain. At 12-month follow-up, no evi-
dence of leakage was observed. To our knowledge, this is
the first case of endoprosthesis implantation in a patient,
who was a poor candidate for surgical intervention due to
renal failure, leucocytosis and high fever, having a chron-
ically contained AAA ruptured simulatingspodilodiscitis
abscess. Appropriate diagnosis and therapy resolved
potentially crippling pathology and avoided surgical graft-
related complications.
Keywords Abdominal aortic aneurysm 
Endoprosthesis implantation  Vertebral erosion
Lumbar pain is a nonspecific sign of disease. Among the
factors that determine its onset, the presence of a chronic
broken aneurysm is an uncommon but valid indication for
surgery. Choplin et al. [l] described a ruptured abdominal
aortic aneurysm (AAA) simulating pyogenic vertebral
spondylitis with vertebral erosion in 1982. Others investi-
gators [2–5] reported chronically contained AAA rupture
as early as 1986. In our case, Multislice computed
tomography (msCT) and magnetic resonance imaging
(MRI) helped differentiate the cause of the vertebral lysis
as a chronically contained AAA rupture rather than oste-
omyelitis. Diagnostic imaging, integrated with
endovascular approach, correctly identified this pathology
and allowed us to resolve it in a less-invasive manner.
Case Report
A 69-year-old man with a 3-year clinical history of end-
stage renal failure and dialysis and an AAA, as previously
diagnosed by Doppler UltraSound (US), located below the
origin of the renal artery. He presented at our hospital with
fever (38.5C, duration 1 week), leucocytosis (12,000/fll),
persistent low back pain transmitted to the left gluteus-
crural region that did not respond to corticosteroids and
nonsteroidal anti-inflammatory drugs.
A msCT scan was performed (Light Speed Plus [4
rows]; General Electric) (Fig. 1) to exclude aneurismal
fissuration; this confirmed an AAA (7 cm in diameter)
located just 1.5 cm below the renal arteries and extending
to the iliac bifurcation. Apparent maximum diameter of the
lesion reached [17 cm because of its extension along the
R. Gandini  M. Chiocchi  L. Maresca  V. Pipitone 
M. Messina  G. Simonetti
Department of Diagnostic and Molecular Imaging,
Interventional Radiology, Nuclear Medicine and Radiation
Therapy, University of Rome ‘‘Tor Vergata, 81 Oxford Street,
Rome 00133, Italy
R. Gandini (&)
Department of Radiology, University of Rome ‘‘ Tor Vergata ,’’,
81 Oxford street, Rome 00133, Italy
e-mail: marcello.chiocchi@fastwebnet.it
123
Cardiovasc Intervent Radiol (2008) 31:S62–S66
DOI 10.1007/s00270-007-9154-y
paravertebral spaces into a mass with soft-tissue density.
This mass, extending to the common iliac arteries, pre-
sented intralesional air bubbles and a thick, calcified
peripheral ring and infiltrated the ileo-psoas muscles, with
lysis of the fourth lumbar vertebra. No narrowing of the
spinal canal was present.
This msCT finding, because of the presence of both
intralesional air with a ring enhancement and extension
into the left pelvis, showed what was suspected to be os-
teomyelytic spondylolysis with paraspinal abscess that had
probably fistulised into the aorta.
To confirm the presence of nerve involvement and
ensure the inflammatory origin of the mass, magnetic res-
onance angiogram (MRA) (1.5T Achieva Philips Medical
System; Best, The Netherlands) was performed by means
of spiral sagittal TI-T2–weighted coronal gradient-echo
(GE) sequences and axial and sagittal contrast-enhanced
T1-weighted sequences.
The lesion showed central isointense and peripheral
hyperintense signals compared with muscle intensity on Tl-
weighted images, and it showed central hyperintensity and
peripheral heterogeneous signal intensity on T2-weighted
images. No enhancement was detected in or around the
lesion.
Signal intensity alteration of L4, with lytic aspect of the
soma and poor discal involvement, were noted (Figs. 2A
and 2B). Because there was no discernible plane between
the dilated aorta and the mass, it was thought to be a
pseudo aneurysm of the aorta eroding into the vertebra;
moreover, the results of msCT-guided needle aspiration
using a 19G 20-cm needle with a 5F (outer diameter)
sheath (TLA needle sheath; Boston Scientific, Watertown,
MA) in the site of the psoas fluid collection demonstrated
dense, brown fluid with some particles of blood clot, but no
pathologic organisms grew on cultures.
After conferring with the vascular surgeon and anaes-
thesiologist, it was decided to perform endovascular
exclusion of the aneurysm. Radiologists planned the en-
dovascular treatment and the choice of type and dimension
of the device based on msCT findings and intraprocedural
angiography.
A team of two vascular surgeons and two interventional
radiologists performed the procedure in an Angio-Suite
(ARC X12; Philips Medical Systems, Best, The Nether-
lands). Surgical exposure of both femoral arteries and
placement of an aortic endoprosthesis (main body 28-mm
diameter, iliac segments 14.5 mm, and length 16 cm
[Excluder; Gore, Flagstaff, AZ]) was accomplished using
the left femoral approach, and left hypogastric artery em-
bolisation with five Gianturco coils (Cook, Bloomington,
IN) was carried out by the interventional radiologists. A
contralateral endoprosthesis (proximal diameter 16 mm,
distal diameter l4 mm, and length 12 cm) plus an aortic
extender (diameter 23 mm and length 3.3 cm) (Excluder)
was subsequently positioned in the aneurysmatic right iliac
artery. Postprocedural angiography showed exclusion of
the aneurysmatic sac, and despite the patient’s renal failure,
Fig. 1 Abdominal multislice computed tomography (msCT) msCT
image shows an infrarenal AAA rupture with vertebral body erosion
Fig. 2 (A) T1-weighted/TSE (Turbo Spin Echo) sagittal (TE 12, TR
682) and (B) T2-weighted/FFE (Fast Field Echo) sagittal (TE 9.2, TR
450) MRI images of the lumbar spine shows a large defect in the
fourth lumbar vertebrae. The anterior margins of the vertebrae are
completely eroded by what appears to be a predominantly preverte-
bral mass. The posterior margin of the aorta is not well depicted on
these sequences
R. Gandini et al.: Chronic Contained Rupture of an Abdominal Aortic Aneurysm S63
123
there was preservation of renal artery patency and no in-
traprocedural complications.
Antibiotic therapy with amoxicillin (2 g/d) was admin-
istrated 1 day previous to and for 5 days after the
intervention. Postprocedural therapy was adopted only in
this case cause of patient’ leucocytosis. The patient was
discharged 11 days after in hospital admission with
decreased lumbar pain, most of which could be managed
with nonsteroidal anti-inflammatory drugs.
No pathologic organisms or infection were noted at the
time of the patient’s discharge (leucocytes 8000/fll). At 1-,
6-, and 12-month follow-up (Fig. 3), preferred msCT
color-Doppler UltraSound and to other x-ray exams, no
evidence of leakage nor increase or decrease of the an-
eurismal diameter was observed; however, the patient still
had some residual back pain, caused by excessive bone
loss, that was not solvable with vertebroplasty.
Discussion
Rupture of an AAA is a surgical emergency with a mor-
tality rate, if untreated, of 90% at 6 weeks and an operative
mortality rate of 30% to 60% [6–9]. In patients without
hypertension [1, 10–12], a sealed aneurism could occur,
without any significant change in blood values because of
restricted blood loss. These patients are often clinically
stable for prolonged periods and are defined as having a
chronically contained rupture (also termed ‘‘sealed,’’
‘‘spontaneously healed,’’ or ‘‘leaking’’) of the AAA [2, 3,
13].
Sealed rupture of an AAA causing vertebral erosion is
rare, and on review of the literature, we found only a few
such cases [1, 4, 5, 10, 11, 14, 15]. All patients had normal
or high blood pressure, and they were hemodynamically
stable at initial presentation. The most common presenting
symptom was back pain; the duration of symptoms ranged
from 2 weeks to 2 years. The mechanism of chronically
contained AAA rupture is not clear. It is believed that in
large aneurysms, a strong perianeurysmal reaction subse-
quently provides high resistance to extravasation of blood
[13].
Moreover, the site of sealed AAA rupture has been
reported as posterior in 62.5% of cases, suggesting that
vertebrae can tamponade the rupture effectively because of
their inherent strength [13]; transmitted arterial pulsation
and vertebral compression of 80 to 90 times/min may
produce extensive bone destruction with time [13],
involving nerve roots or fibers that pass around muscles [7,
15–17]. Erosion caused by aneurysms is usually smooth
compared with that caused by pyogenic infection, in which
the margins of the lytic process are irregular and poorly
defined [3, 18].
msCT and MRI are fundamental to accurate and timely
diagnosis. They are necessary to assess adequate interven-
tion to avoid rupture into the intraperitoneal or
Fig. 3 Abdominal multislice spiral CAT. Abdominal CAT shows
total exclusion of the aneurysmatic sac after positioning of the
endoprosthesis
Fig. 4 T1-weighted/FFE/MIP (Maximum Intensity Projection) coro-
nal (TE 1.3, TR 17) MRI images. Angio-MRI coronal-MIP shows a
large infrarenal AAA extending to the left and right common iliac
arteries
S64 R. Gandini et al.: Chronic Contained Rupture of an Abdominal Aortic Aneurysm
123
retroperitoneal cavity and the surrounding hollow structures
(e.g., veins and bowel). Diagnostic imaging can also be used
to accurately distinguish abdominal or back pain attributable
to ruptured AAA from other causes [14, 17–23].
Our case report demonstrates how appropriate diagnosis
and therapy can resolve crippling pathology and avoid
surgical graft-related complications, such as pseudoaneu-
rysm or haemorrhage at the anastomotic site, graft
thrombosis, atheroembolism or infection, graft-enteric
erosion, and colon ischaemia. A complication rate of 9.4%,
especially in a patient such as ours, who was a poor can-
didate for surgery, has been reported [9, 14, 22].
msCT or MRA, integrated with endovascular therapy,
provides an invaluable, less-invasive means by which to
depict and exclude the aneurysmal sac; provides prompt
repair of this dangerous pathology, which is difficult to
identify; and re-establishes an acceptable quality of life for
the patient.
To our knowledge, this is the first case of endoprosthesis
implantation in a patient, who was a poor candidate for
surgical intervention, with chronically contained AAA
rupture simulating a spodilodiscitis abscess.
References
1. Choplin RH, Karstaedt N, Wolfman NT (1982) Ruptured
abdominal aortic aneurysm simulating pyogenic vertebral spon-
dylitis. AJR Am J Roentgenol 138:748–750
2. Rosenthal D, Clark MD, Stanton PE, et al. (1986) ‘‘Chronic-
contained’’ ruptured abdominal aortic aneurysm: Is it real? J
Cardiovasc Surg (Torino) 27:723–724
3. Jones CS, Reilly KM, Dalsing MC, et al. (1986) Chronic con-
tained rupture of abdominal aortic aneurysm. Arch Surg
121:542–545
4. Bansal M, Bansal M, Thukral BB, et al. (2006) Contained rupture
of a thoracoabdominal aortic aneurysm presenting as a back
mass. J Thorac Imaging 21(3):219–221
5. Saiki M, Urata Y, Katoh I, et al. (2006) Chronic contained rup-
ture of an abdominal aortic aneurysm with vertebral erosion:
Report of a case [review]. Ann Thorac Cardiovasc Surg
12(4):300–302
6. Gavant ML, Salazar JE, Ellis J (1986) Case report. Intrarenal
rupture of the abdominal aorta: CT features. J Comput Assist
Tomogr 4:529–532
7. Darling RC (1970) Ruptured arteriosclerotic abdominal aortic
aneurysms. A pathologic and clinical study. Am J Surg 119:402–
407
8. Dillon M, Cardwell C, Blair PH, et al. (2007) Endovascular
treatment for ruptured abdominal aortic aneurysm [review].
Cochrane Database Syst Rev 24(1):CD005261
9. Biancari F, Ylonen K, Anttila V, Juvonen J, Romsi P, Satta J,
et al. (2002) Durability of open repair of infrarenal abdominal
aortic aneurysm: A 15-year follow-up study. J Vasc Surg
35(1):87–93
10. Prete PE, Thorne RP, Robinson CA (1980) Low-back pain and
vertebral erosion due to aortic anastomotic false aneurysm, with
documentation by computerized tomography: A case report. J
Bone Joint Surg Am 62:126–128
11. Galessiere PF, Downs AR, Greenberg HM (1994) Chronic,
contained rupture of aortic aneurysms associated with vertebral
erosion. Can J Surg 37:23–28
12. Szilagyi DE (1982) Clinical diagnosis of intact and ruptured
abdominal aortic aneurysms. In: Bergan JJ, Yao JST (eds)
Aneurysms: Diagnosis and treatment. New York, NY, Grune &
Stratton, pp 205–216
13. Sterpetti AV, Blair EA, Schultz RD, et al. (1990) Sealed rupture
of abdominal aortic aneurysms. J Vasc Surg 11:430–435
Fig. 5 Diagnostic angiography with centimetred pig-tail confirmed a
large infrarenal AAA with a proximal neck 1.5 cm in length
Fig. 6 Angiography after position of the endoprosthesis demon-
strates complete exclusion of the aneurysmatic sac
R. Gandini et al.: Chronic Contained Rupture of an Abdominal Aortic Aneurysm S65
123
14. Kapoor V, Kanal E, Fukui MB (2001) Vertebral mass resulting
from a chronic-contained rupture of an abdominal aortic
aneurysm repair graft. AJNR Am J Neuroradiol 22(9):1775–
1777
15. Defraigne JO, Sakalihasan N, Lavigne JP, et al. (2001) Chronic
rupture of abdominal aortic aneurysm manifesting as crural
neuropathy [review]. Ann Vasc Surg 15(3):405–411
16. Higgins R, Peitzman AB, Reidy M, et al. (1998) Chronic con-
tained rupture of an abdominal aortic aneurysm presenting as a
lower extremity neuropathy. Ann Emerg Med 17:284–287
17. Ando M, Igari T, Yokoyama H, et al. (2003) CT features of
chronic contained rupture of an abdominal aortic aneurysm. Ann
Thorac Cardiovasc Surg 9:274–278
18. Jacquot JM, Strubel D, Joyeux A, et al. (1996) Sealed rupture of
an abdominal aortic aneurysm with chronic vertebral destruction
as the first manifestation. Contribution of computed tomography
to the diagnosis. Rev Rhum Engl Ed 63(5):377–379
19. William LR, Flinn WR, Yao JST (1985) Extended use of com-
puted tomography in the management of complex aortic problem:
a learning experience. J Vasc Surg 4:264–271
20. Senapatti A, Hurst PAE, Thomas IL (1986) Differentiation of
ruptured aortic aneurysm from acute expansion by computerized
tomography. J Cardiovasc Surg (Torino) 27:719–722
21. Johnson WC, Gale ME, Gerzol SG (1986) The role of computed
tomography in symptomatic aortic aneurysms. Surg Gynecol
Obstet 162:49–53
22. Hallet JW Jr, Marshall DM, Petterson TM, et al. (1997) Graft-
related complications after abdominal aortic aneurysm repair:
Reassurance from a 36-year population-based experience. J Vasc
Surg 25:277–286
23. Schwartz SA, Taljanovic MS, Smyth S, et al. (2007) CT findings
of rupture, impending rupture, and contained rupture of abdom-
inal aortic aneurysms [review]. AJR Am J Roentgenol
188(1):W57-W62
S66 R. Gandini et al.: Chronic Contained Rupture of an Abdominal Aortic Aneurysm
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Chronic Contained Rupture of an Abdominal Aortic Aneurysm: From Diagnosis to Endovascular Resolution

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