Extremity and Visceral Aneurysms

An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries than in veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins and are at risk of dissection and rupture, which can be life-threatening. Peripheral aneurysms affect arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries of the extremities or the viscera (organs). Aneurysms in the upper and lower limbs may present with symptoms of ischemia due to the development of an intramural thrombus. Visceral aneurysms affect the celiac, splenic, or superior mesenteric arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries and may present with vague abdominal symptoms or signs of an acute abdomen Acute Abdomen Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammation, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Acute Abdomen. Management is usually surgical to prevent rupture; however, observation in asymptomatic nonpregnant individuals may be appropriate for smaller aneurysms.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

An aneurysm is a bulging, weakened area of a blood vessel, usually an artery, that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel.

Classification

  • Types:
    • True aneurysm: involves all 3 layers of the vessel wall with ≥ 1 layer intact
    • Pseudoaneurysm: blood escapes into surrounding tissues and forms a hematoma around the artery as a result of a tear in the vessel wall.
  • Shape:
    • Saccular aneurysm: sac-like bulging on 1 side of a blood vessel
    • Fusiform aneurysm: elongated spindle-shaped dilation of a blood vessel

Etiology

  • Atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis (both extremity and visceral aneurysms)
  • Trauma
  • Iatrogenic (e.g., dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis fistula)
  • Behçet syndrome (most commonly pulmonary artery aneurysm)
  • Hereditary conditions:
    • Marfan syndrome Marfan syndrome Marfan syndrome is a genetic condition with autosomal dominant inheritance. Marfan syndrome affects the elasticity of connective tissues throughout the body, most notably in the cardiovascular, ocular, and musculoskeletal systems. Marfan Syndrome
    • Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome

Extremity Aneurysms

Upper-limb aneurysms

Upper-limb aneurysms are rare and can involve the branches of the aortic arch Aortic arch The branchial arches, also known as pharyngeal or visceral arches, are embryonic structures seen in the development of vertebrates that serve as precursors for many structures of the face, neck, and head. These arches are composed of a central core of mesoderm, which is covered externally by ectoderm and internally by endoderm. Branchial Apparatus and Aortic Arches extending to the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand. Symptoms are caused by thrombus formation, distal emboli, or local expansion. Most upper-extremity aneurysms should be surgically repaired to reduce the risk of stroke.

Location:

  • Proximal: involve the subclavian or axillary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
  • Distal: involve the ulnar, palmar, or brachial arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries

Etiology:

  • Most commonly due to trauma
  • Idiopathic

Clinical presentation: 

  • Pulsatile mass
  • Pain in digits
  • Arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm swelling
  • Neurologic deficits:
    • Pain
    • Numbness
    • Paresthesia
    • Weakness
  • Thrombus formation
  • Acute limb ischemia Acute limb ischemia Acute limb ischemia (ALI) is a major vascular emergency because of the rapid decrease in limb perfusion that causes a potential threat to limb viability. The majority of cases are caused by arterial thrombosis due to plaque progression or embolism, but ALI can also be caused by blockage of the venous drainage. Acute Limb Ischemia: 6 Ps of arterial occlusion
    • Pulselessness
    • Pallor
    • Pain
    • Poikilothermia (inability to maintain core body temperature)
    • Paresthesia 
    • Paralysis
  • Microemboli:
    • Finger pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Cyanosis
    • Ulceration
    • Subungual splinter hemorrhages
Right-upper-arm av fistula aneurysm

Right-upper-arm (brachiocephalic) arteriovenous (AV) fistula aneurysm

Image: “Right upper arm AV fistula aneurysm of the patient” by College of Medicine at Urbana-Champaign, University of Illinois. License: CC BY 3.0

Diagnosis:

  • Ultrasonography and color Doppler
  • CT
  • MRI
  • MRA
  • DSA (digital subtraction angiography)

Management:

  • Endovascular surgery with stent placement
  • Open resection with revascularization

Lower limb: popliteal aneurysm

Epidemiology: 

  • Popliteal aneurysms are the most common lower-limb aneurysm.
  • Men > women 
  • Mean age at presentation: 65 years
  • 60% are symptomatic; 40% are asymptomatic incidental findings.

Risk factors (for atherosclerosis):

  • Smoking
  • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Diabetes
  • Cardiac disease
  • Older age: > 55
  • Hyperlipidemia

Clinical presentation:

  • Palpable mass at the back of the knee ( popliteal fossa Popliteal fossa The popliteal fossa or the "knee pit" is a diamond-shaped, fat-filled, shallow depression on the posterior aspect of the knee joint. The popliteal fossa is located at the dorsal aspect of the knee and contains an increased number of lymph nodes as well as structures of the neurovascular system that travel from the thigh to the lower leg. Popliteal Fossa)
    • Bilateral in 50% of individuals
    • Usually called aneurysmal > 2 cm
  • Acute limb ischemia Acute limb ischemia Acute limb ischemia (ALI) is a major vascular emergency because of the rapid decrease in limb perfusion that causes a potential threat to limb viability. The majority of cases are caused by arterial thrombosis due to plaque progression or embolism, but ALI can also be caused by blockage of the venous drainage. Acute Limb Ischemia: 6 Ps of arterial occlusion
    • Pulselessness
    • Pallor
    • Pain
    • Poikilothermia
    • Paresthesia 
    • Paralysis
  • Compressive symptoms
    • Knee pain Knee Pain Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. Knee Pain
    • Paresthesia or numbness (sciatic, peroneal, or tibial nerves)
    • Varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins 
  • Chronic ischemia
    • Claudication
    • Rest pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • “Blue toe syndrome”: digital ischemia with intact large-vessel circulation from cardiac emboli
  • Rupture → severe knee pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with swelling

Diagnosis:

  • Duplex ultrasonography
    • Best diagnostic test
    • Visualizes thrombus
    • Measures diameter
    • Excludes other anatomic abnormalities such as Baker cyst
  • CTA/MRA for elective surgeries
Popliteal artery aneurysm

Preoperative CT angiography with a 3-dimensional reconstruction of popliteal artery aneurysm

Image: “ Preoperative CTA angiography three-dimensional reconstruction showing popliteal artey aneurysm location” by Department of Vascular Surgery Vascular surgery Vascular surgery is the specialized field of medicine that focuses on the surgical management of the pathologies of the peripheral circulation. The main goal of most vascular procedures is to restore circulatory function to the affected vessels by relieving occlusions or by redirecting blood flow (e.g., bypass). Vascular Surgery, San Filippo Neri Hospital, Rome. License: CC BY 4.0

Management:

  • Medical:
    • Risk factor modification (e.g., smoking cessation, control blood pressure)
    • Anticoagulation for acute limb ischemia or critical stenosis (risk of thrombosis)
    • Serial imaging may be done for smaller aneurysms.
  • Surgical indications:
    • Acute limb ischemia Acute limb ischemia Acute limb ischemia (ALI) is a major vascular emergency because of the rapid decrease in limb perfusion that causes a potential threat to limb viability. The majority of cases are caused by arterial thrombosis due to plaque progression or embolism, but ALI can also be caused by blockage of the venous drainage. Acute Limb Ischemia
    • Elective aneurysm > 2 cm
    • Thrombus on imaging
    • Symptomatic individuals with collateral circulation

Lower limb: iliofemoral aneurysm

Epidemiology: 

  • 2nd most common peripheral aneurysm
  • 40% of individuals have an associated abdominal aortic aneurysm ( AAA AAA An aortic aneurysm is the abnormal dilation of a segment of the aorta. Abdominal aortic aneurysm is the most common aortic aneurysm, occurring frequently in the infrarenal area. Most aneurysms are asymptomatic, but can cause compression of surrounding structures or rupture, which is a life-threatening emergency. Abdominal Aortic Aneurysms)

Clinical presentation:

  • Unruptured:
    • Lower abdominal, back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain or groin pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Pain and numbness in the leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg
    • Leg edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema due to adjacent vein compression
    • Acute limb ischemia Acute limb ischemia Acute limb ischemia (ALI) is a major vascular emergency because of the rapid decrease in limb perfusion that causes a potential threat to limb viability. The majority of cases are caused by arterial thrombosis due to plaque progression or embolism, but ALI can also be caused by blockage of the venous drainage. Acute Limb Ischemia 
    • Blue toe syndrome = digital ischemia with intact large vessel circulation from cardiac emboli
  • Ruptured:
    • Acute abdominal, thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh, or groin pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Hemodynamic instability
  • Asymptomatic: incidental finding on exam
    • Palpable thrill/audible bruit 
    • Painless pulsatile swelling in the groin
True aneurysm

Left iliofemoral aneurysm

Image: “True aneurysm” by Jojo. License: Public Domain

Management:

  • Medical treatment same as for popliteal aneurysms
  • Surgical indications:
    • Symptoms 
    • Coexisting AAA AAA An aortic aneurysm is the abnormal dilation of a segment of the aorta. Abdominal aortic aneurysm is the most common aortic aneurysm, occurring frequently in the infrarenal area. Most aneurysms are asymptomatic, but can cause compression of surrounding structures or rupture, which is a life-threatening emergency. Abdominal Aortic Aneurysms
    • Rapid expansion
    • Iliac artery aneurysm size > 3 cm

Visceral Artery Aneurysms

Visceral artery aneurysms (VAAs) can affect the celiac artery, the superior and inferior mesenteric arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries, or their branches.

Epidemiology: 

  • Rare; incidence is 0.1%–0.2%.
  • Splenic artery aneurysm (60% of VAAs): 
    • 80% > age 50
    • Incidence: 4x more common in women than in men
    • Seen after liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver transplantation
  • Hepatic artery aneurysm (20% of VAAs)
    • 80% are extrahepatic
    • Twice as common in men as in women
    • Higher risk of rupture than other VAAs
    • Many individuals have other VAAs or nonvisceral aneurysms.
  • Superior mesenteric artery aneurysm (5%–7%):
    • Usually due to atherosclerosis
    • Associated with polyarteritis nodosa, Behçet syndrome, and systemic connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue disorders
  • Celiac artery aneurysm (3%–4% of VAAs)

Risk factors: 

  • Atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis (32% of VAAs)
  • Medial degeneration in fibromuscular dysplasia Fibromuscular dysplasia Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory, medium-sized angiopathy due to fibroplasia of the vessel wall. The condition leads to complications related to arterial stenosis, aneurysm, or dissection. Fibromuscular Dysplasia (24%)
  • Abdominal trauma (22%)
  • Conditions of increased blood flow:
    • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • Portal hypertension Portal hypertension Portal hypertension is increased pressure in the portal venous system. This increased pressure can lead to splanchnic vasodilation, collateral blood flow through portosystemic anastomoses, and increased hydrostatic pressure. There are a number of etiologies, including cirrhosis, right-sided congestive heart failure, schistosomiasis, portal vein thrombosis, hepatitis, and Budd-Chiari syndrome. Portal Hypertension (splenic artery aneurysm)
    • Liver transplantation
  • Heart valve infection
  • Connective tissue disorders
    • Marfan syndrome Marfan syndrome Marfan syndrome is a genetic condition with autosomal dominant inheritance. Marfan syndrome affects the elasticity of connective tissues throughout the body, most notably in the cardiovascular, ocular, and musculoskeletal systems. Marfan Syndrome
    • Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome
    • Kawasaki disease Kawasaki disease Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome or infantile polyarteritis, is a medium-sized necrotizing febrile vasculitis that affects children < 5 years of age. Multiple systems are involved but the most serious is the predilection of the coronary arteries. Kawasaki Disease
    • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)

Clinical presentation:

  • Most VAAs are found incidentally on abdominal imaging done for other reasons.
  • Nonspecific symptoms:
    • Malaise
    • Vague abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Nausea or vomiting
    • Celiac artery aneurysms can mimic pancreatitis.
  • Embolic event → acute mesenteric ischemia Mesenteric Ischemia Mesenteric ischemia is a rare, life-threatening condition caused by inadequate blood flow through the mesenteric vessels, which results in ischemia and necrosis of the intestinal wall. Mesenteric ischemia can be either acute or chronic. Mesenteric Ischemia
  • Rupture: 
    • Hemorrhagic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
    • Acute abdomen 

Diagnosis:

  • Abdominal x-ray may show crescent-shaped calcification.
  • Duplex ultrasonography
    • Round, hypoechoic mass seen
    • Ideal for intrahepatic aneurysm
    • Indicated in pregnant individuals
  • CTA or MRA for surgical planning
Ultrasound scan of aneursyma

Ruptured hepatic artery aneurysm presenting as abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain:
Ultrasound scan shows aneurysmal sac to the left of the common bile duct and portal vein.

Image: “Ultrasound scan showing aneurysmal sac to the left of the common bile duct and portal vei” by Department Of General Surgery, Queen Elizabeth II Hospital Howlands, Welwyn Garden City. License: CC BY 3.0

Management:

  • Early elective treatment is the general approach to minimize the risk of rupture, but there is no consensus guideline for observation versus surgery in VAAs < 2.5 cm.
  • Definite surgical indications:
    • Symptomatic VAAs
    • Asymptomatic aneurysms with rapid expansion > 0.5 cm/year
    • Pregnant individuals
    • Pseudoaneurysms (regardless of symptoms) due to higher risk of rupture
  • Ruptured VAA:
    • Stabilize individual; transfuse blood and platelets Platelets Platelets are small cell fragments involved in hemostasis. Thrombopoiesis takes place primarily in the bone marrow through a series of cell differentiation and is influenced by several cytokines. Platelets are formed after fragmentation of the megakaryocyte cytoplasm. Platelets
    • Specific embolization techniques depend on the location, affected organ, and availability of a skilled interventional radiologist.
    • Endovascular repair with coils
    • Percutaneous thrombin injection (rarely used)
    • Surgical exploration with clipping and evacuation of any hematoma present

Prognosis:

  • Ruptured VAAs: 25%–70% mortality rate
  • Repaired aneurysm: immediate success in 90%

Differential Diagnosis

Extremity aneurysms

  • Popliteal cyst (Baker cyst): most common cause of a palpable mass in the popliteal fossa Popliteal fossa The popliteal fossa or the "knee pit" is a diamond-shaped, fat-filled, shallow depression on the posterior aspect of the knee joint. The popliteal fossa is located at the dorsal aspect of the knee and contains an increased number of lymph nodes as well as structures of the neurovascular system that travel from the thigh to the lower leg. Popliteal Fossa. Popliteal cysts are formed by the extrusion of synovial fluid from the knee joint Knee joint The knee joint is made up of the articulations between the femur, tibia, and patella bones, and is one of the largest and most complex joints of the human body. The knee is classified as a synovial hinge joint, which primarily allows for flexion and extension with a more limited degree of translation and rotation. Knee Joint and may present similarly to a ruptured aneurysm, with an acute onset of severe knee pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain if it ruptures. Diagnosis can be made by physical exam, but ultrasonography is confirmatory. These cysts are commonly associated with osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis or inflammatory arthritis. Treatment is with direct injection or aspiration of the cyst.
  • Peripheral arterial disease (PAD): result of atherosclerosis gradually obstructing the arterial lumen and causing decreased blood flow to the distal limbs. Symptoms range from claudication to skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin discoloration and ischemic ulcers to gangrene. Diagnosis is made by physical exam with decreased palpable pulses. Additional studies include ankle brachial index testing and angiography if needed for surgical evaluation. Management is with lifestyle change (e.g., smoking cessation), antiplatelet therapy, and revascularization.

Visceral aneurysms

  • Biliary colic: aneurysm in the hepatic arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries may cause RUQ pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain mimicking biliary colic, especially if there is rupture and the individual has associated jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice. Imaging with ultrasonography or CT is essential for differentiating from other etiologies, such as gallstones. Treatment is based on the underlying etiology.
  • Pancreatitis: aneurysm of the celiac artery may mimic pancreatitis owing to its retroperitoneal location. Presentation is with dull pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the epigastric region that radiates to the back. Ultrasonography is an important diagnostic tool in identifying an aneurysm, and laboratory findings may include elevated amylase and lipase.

References

  1. Reed, A.B. (2020). Popliteal artery aneurysm. UpToDate. Retrieved November 3, 2021, from https://www.uptodate.com/contents/popliteal-artery-aneurysm
  2. Sumpio, B. (2020). Overview of visceral artery aneurysm and pseudoaneurysm. UpToDate. Retrieved November 3, 2021, from https://www.uptodate.com/contents/overview-of-visceral-artery-aneurysm-and-pseudoaneurysm
  3. Landry, G. (2021). Overview of aneurysmal disease of the aortic arch branches or upper extremity arteries in adults. UpToDate. Retrieved November 3, 2021, from https://www.uptodate.com/contents/overview-of-aneurysmal-disease-of-the-aortic-arch-branches-or-upper-extremity-arteries-in-adults
  4. Hall, H.A., Minc, S., Babrowski, T. (2013). Peripheral artery aneurysm. Surgical Clinics of North America 93:911–23, ix. https://pubmed.ncbi.nlm.nih.gov/23885937/
  5. Kuntz, S., Lejay, A., Georg, Y., Thaveau, F., Chakfé, N. (2020). Management of upper extremity aneurysms: a systematic review. International Angiology 3:61–70. https://pubmed.ncbi.nlm.nih.gov/32052949/
  6. Chiaradia, M., et al. (2015). Ruptured visceral artery aneurysms. Diagnostic and Interventional Imaging 96:797–806. https://doi.org/10.1016/j.diii.2015.03.012

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