Vertebral mass resulting from a chronic-contained rupture of an abdominal aortic aneurysm repair graft

Abstract

We describe a case of a 63-year-old man with chronic-contained rupture of an abdominal aortic aneurysm at the site of prior graft repair of the aneurysm. Initially misinterpreted as osteomyelitis on the basis of CT findings, this chronic-contained rupture of the abdominal aorta eroding the vertebrae was preoperatively diagnosed at MR imaging and confirmed at surgery. A conventional angiogram failed to show the pseudoaneurysm. Owing to a major difference in the management of a contained aortic aneurysm rupture versus that for osteomyelitis, MR imaging with CT or MR angiography is recommended before any operative or invasive procedure.

fig 1.

Images in a 63-year-old Caucasian man with low back pain 2 years after the repair of an abdominal aortic aneurysm with a graft. A, Axial CT image of the third lumbar vertebra shows a large lytic defect in its body with a cortical discontinuity along the posterior margin (arrow) that suggests epidural extension. B, Axial contrast-enhanced CT image of the abdomen shows a hypoattenuating mass in the third lumbar vertebral body, with left paravertebral soft-tissue extension (arrow). The aorta is enhancing normally, with a crescent of normal peritoneal fat along the left lateral margin. The kidneys are enhancing asymmetrically because of a right renal artery stenosis at the anastomotic site. C–E, Sagittal T1-weighted (655/13/2) (C), sagittal T2-weighted (4000/100/2) (D), and sagittal contrast-enhanced T1-weighted (784/14/1) (E) MR images of the lumbar spine show a large defect in the second and third lumbar vertebrae. The anterior margins of the vertebrae are completely eroded by what appears to be a predominantly prevertebral mass showing minimal enhancement. The posterior margin of the aorta is not well depicted on these images. F and G, Axial T1-weighted (655/13/2) (F) and axial contrast-enhanced T1-weighted (784/14/1) (G) MR images of the third lumbar vertebra show a large mass in the prevertebral and left paravertebral space eroding the anterior margin of the vertebral body, with extension to the anterior epidural space. The mass is extending into the left psoas muscle, and anteriorly, it appears to be continuous with the aorta. H, Dacron grafts are depicted superiorly (clamped) and inferiorly (from previous surgery) medial to the retractor, with a large defect in the posterior wall of the aorta eroding into the vertebral body (center of the photograph).