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A patient in their 80s with PMH of abdominal aortic aneurysm s/p grafting with type 2 endoleak presented to the ED for dizziness. Bedside ultrasound demonstrated an 8.55 cm aortic aneurism with large thrombus. Endoleak is the hypoechoic area seen above the hyperechoic endograft.
Mehtab Galeh, MD; Bayley Espinoza, MD
A patient in their 80s with PMH of abdominal aortic aneurysm s/p grafting with type 2 endoleak presented to the ED for dizziness. Bedside ultrasound demonstrated an 8.55 cm aortic aneurism with large thrombus. Endoleak is the hypoechoic area seen above the hyperechoic endograft.
Mehtab Galeh, MD; Bayley Espinoza, MD
Suprasternal notch view of the aortic arch with brachiocephalic artery (BCA), left common carotid artery (LCA), and left subclavian artery (LSA) branching off. Right pulmonary artery is also visible adjacent to the ascending aorta.
Charles Jang, EM PGY-3
Suprasternal notch view of the aortic arch with brachiocephalic artery (BCA), left common carotid artery (LCA), and left subclavian artery (LSA) branching off. Right pulmonary artery is also visible adjacent to the ascending aorta.
Charles Jang, EM PGY-3
Saccular AAA with Dissection Flap.
Contributor: Daniel Ostapowicz, MD
An elderly woman presented to the ED with dyspnea and left mid back pain for 1 week. Left PLAPS (Posterolateral Alveolar and/or Pleural Syndrome) view revealed a round-shaped pulsatile mass surrounded by pleural effusion & atelectatic lung. CTA later confirmed a partially ruptured, thrombosed thoracic aorta aneurysm. This case illustrates the possibility of quickly diagnosing life-threatening conditions with POCUS.
Contributed by: Caio Sangirardi, Emergency Medicine Resident Quinta D'Or Hospital, Rio de Janeiro - Brazil, @SangirardiMD
Flap seen in the descending aorta consistent with aortic dissection
Contributed by: Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate)
70s-year-old male brought in for altered mental status and hypotension.
As part of the initial exam, POCUS was performed. This clip, obtained using the curvilinear probe in transverse orientation over the mid-epigastric region, revealed a AAA measuring 8 cm in AP diameter at the largest point with heterogeneous echogenic material consistent with thrombus. CT abdomen/pelvis with IV contrast confirmed ruptured AAA with thrombosis and only minor extravasation.
In this case, POCUS played a critical role in the rapid diagnosis of a patient with undifferentiated shock, particularly in a patient who was unable to provide any history.
Katherine Spencer, MD
Guy Youngblood, MD, FACEP, FAAEM
This patient originally complained of right back pain as well as numbness along the thigh and knee. Starting from the abdominal artery, gliding inferiorly will eventually reveal the bifurcation of the abdominal aorta into the left and right common iliac arteries. In this scan, you can see both iliac arteries have enlarged diameters, indicating aneurysms in both.
Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM
Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH
View his original post here
Patient presented with severe chest pain and concerning ECG without STEMI. A faint dissection flap can be seen in the aorta on this transverse view in the subcostal region.
Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM
Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH
View his original post here
Sagittal view of large abdominal aortic aneurysm incidentally found after accidental fall.
Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM
Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH
View his original post here
Here is another example of an abdominal aortic aneurysm that measured approximately 10.6 cm. The patient originally presented to the clinic complaining of a cough and was eventually admitted for surgical operation.
Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM
Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH
View his original post here
The patient presented to the ED with a known abdominal aortic aneurysm (AAA). A point-of-care ultrasound (POCUS) examination of the abdominal aorta was performed using a curvilinear probe (longitudinal view shown). An infrarenal AAA was noted adjacent and superior to the bifurcation and measured a maximum diameter of approximately 5cm. Heterogeneous echogenic material was seen within the lumen of the aneurysm in keeping with intramural thrombosis, along with a hyperechoic line representing a chronic dissection.
This demonstrates the utility of POCUS in the rapid diagnosis of AAA and evaluation of size and intraluminal features such as intramural thrombus and dissection.
Andrew Namespetra, MB BCh BAO MSc
PGY-1 Emergency Medicine Resident, Central Michigan University (CMU)
Chad Bambrick, MD
PGY-2 Emergency Medicine Resident, CMU
Ryan Davis
MS4, CMU College of Medicine
This is a clip demonstrating a large abdominal aortic aneurysm with significant intramural thrombus. Signs of rupture can be appreciated near the right lower portion of the screen as there is disruption of the aorta wall. Heterogeneity within the intramural thrombus can also be an indicator of rupture.
Michael Macias, MD
Sagittal view of an abdominal aortic aneurysm with a hemorrhage anterior to the aorta. Be sure to distinguish a AAA from a dissection by assessing the abnormal wall motion seen at the site of rupture.
Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM
Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH
View his original post here
A chest pain received an echo and showed evidence of a dissection in the PLAX, PSAX, and AP4C views within the descending aorta.
Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM
Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH
View his original post here
Patient presented with symptoms of stroke. Echo revealed pericardial effusion and aortic US showed a dissection flap emphasizing the importance of POCUS prior to TPA.
Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM
Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH
View his original post here
Emergency response was called for an 88-year-old who experienced sudden onset thoracic and back pain. PMH significant for AAA (previously measuring 5.8 cm diameter on surveillance imaging 1 year ago). Mid-abdominal US view was obtained (shown here) and revealed AAA now measuring 7.2 cm diameter.
Wolfgang Geisser
@fentanyl05
61 year-old male presented with one day history of generalized abdominal pain, nausea, and vomiting. He was hemodynamically stable (BP 130/59); EKG notable for the presence of U waves and lateral ST depressions; labs revealed a negative troponin, potassium 3.1, lactic acid 5.4. Abdominal POCUS seen here revealed an abdominal aortic dissection flap as his unifying diagnosis.
Richard Cunningham, MD. Emergency Medicine
This clip represents a normal suprasternal view. The brachiocephalic artery (BCA), left carotid artery (LCA) and left subclavian artery (LSA) emerge from the aortic arch (AA). The left subclavian artery (LSA) marks the division between the proximal thoracic aorta and the distal descending aorta (DA).
Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia.
At the center of the screen, the proximal aorta can be identified by the emergence of the coeliac trunk and the superior mesenteric artery. This clip is taken at the subxiphoid level, longitudinal to the body’s axis, and with the probe marker oriented towards the head.
Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia.
At the center of the screen, the distal aorta lies anterior to a vertebral body. Sliding the probe caudally reveals the emergence of the iliac arteries. This clip is taken at the umbilicus level, transverse to the body’s axis, and with the probe marker oriented to the patient’s right.
Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia.
The two round, anechoic structures laying on top of a hyperechoic vertebra are the IVC to the left of the screen (patient’s right), and the thicker, contractile aorta to the right (patient’s left). Deep inspiration or a sniff test demonstrates a collapsible IVC in normal subjects. Consider, however, that visualization of both these vessels may certainly be obscured by very obese patients or those with subcutaneous emphysema, significant bowel gas, ascites, or a large ventral hernia.
This clip is taken over the subxiphoid region, transverse to the body’s axis, and with the probe marker oriented to the patient’s right.
Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia.
While maintaining its orientation, the probe is dragged to the left of the patient, revealing the abdominal aorta (AA) and the emergence of the coeliac trunk. Notice the contractile, thicker aortic walls and how both the common hepatic artery and splenic artery form the “seagull sign”. Also notice that a normal IVC frequently demonstrates transmitted pulsations from the RA; hence, pulsation is not the proper method for differentiating it from the aorta.
This clip is taken over the subxiphoid region, longitudinally to the body’s axis, and with the probe marker oriented to the patient’s head.
Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia.
Long axis view of large abdominal aortic aneurysm containing intramural thrombus without evidence of the iliac arteries involvement.
Image courtesy of Giovanni Battista Fonsi
A 61-year-old male was brought in via EMS after a syncopal episode. He was diaphoretic and hypotensive, complaining of severe right flank pain.
While IV access was being obtained a bedside ultrasound was performed demonstrating a large abdominal aortic aneurysm with significant heterogeneous intraluminal clot. There is also appreciable focal hypoechoic disruption of the wall of the aneurysm consistent with rupture.
The patient was resuscitated in the ED and taken emergently to the OR to surgical repair.
Michael Macias, MD
In the beginning of this clip we see several major structures in one view. From superficial to deep: liver, pancreas, splenic vein draining into the portal confluence, superior mesenteric artery in transverse (surrounded by a hyperechoic layer of fat creating the “mantle clock sign”), IVC with the left renal vein branching off, and the abdominal aorta. A vertebral body is visible at the bottom of the screen. As the probe is moved caudally, most of these vessels move out of plane and we are left following the course of the IVC and aorta inferiorly.
The vertebrae, seen here as the deepest structure as a hyperechoic arch with posterior shadowing (horseshoe sign), is a key anatomic reference when scanning the aorta. The aorta is located immediately anterior to the vertebrae and to the right side on the screen (patient’s left). Contrast this with the inferior vena cava, which is seen to the left of the aorta, often in an oval or teardrop shape. In the center of the screen we see the celiac trunk branching off the proximal abdominal aorta. The Y-shaped “seagull sign” is created by the celiac trunk as it branches into the hepatic artery (left) and splenic artery (right). The portal venous confluence is visible between the IVC and the hepatic artery.
In the center of the screen we see the distal aorta in transverse view. As the probe is moved caudally, the aorta bifurcates into the two common iliac arteries. Deep to the aorta we see the round hyperechoic edge of the vertebral body and to the left of the aorta we see the more compressible inferior vena cava.
A 70-year-old male presented as a trauma alert and was found to have this 10 cm abdominal aortic aneurysm (AAA) with associated echocardiographic smoke! Echogenic smoke is produced by the intersection of RBC’s and plasma proteins at low shear rate conditions.
Brian Toston, Internist. Adventura, FL