Sex: male
Age: 70 years

History
Not known.

Laboratory data
Laboratory tests revealed severe renal insufficiency.

Physical findings
Pulsatile abdominal mass on palpation. Hypertension.

Case text
A 70 year old man was admitted to the hospital with a pulsatile abdominal mass, hypertension, and signs for moderate arteritis of left lower limb.

Image 1
Abdominal ultrasound with Doppler evaluation was performed.
Ultrasound examination showed a 6 cm diameter aneurysm of the aorta. The Duplex waveform recorded in the proximal left renal artery is shown.

Image 2-5
MR angiography.
3D fast gradient echo acquisition (3D EF-GRE) after injection of a bolus of Gadolinium
(see discussion for more details). Image 4 is a reconstruction obtained after pasting the images from the previous figures.

Image 1

1.Which imaging modality do you recommend to be performed in this case?

- Spiral CT?
- Angiography?
- MR Angiography ?
CT scan could be helpful in evaluating the aortic aneurysm, and the renal artery stenosis. However, it cannot give any information on the arteries of both lower limbs which are required as regards the arteritis. Moreover, injection of a significant amount of iodine injection is mandatory, which should be avoided because of the severe renal dysfunction;
Angiography also requires iodine contrast injection. It is an invasive procedure, which should be associated with interventional therapy.
MR Angiography is the procedure of choice in the present case. First of all, it is a non invasive method which it doesn't require injection of iodine contrast agent. It allows in the same acquisition, with a single bolus of gadolinium, to evaluate the entire arterial system, from the upper abdominal aorta down to the distal arteries.

Image 2-5

2. What are the main lesions that you can see on these images?

Image 2 nicely depicts the proximal, severe stenosis of the left renal artery, associated with some degree of dilation of the post stenotic segment. It also shows the irregular lumen of the aortic aneurysm, developing a few centimeters below the level of renal arteries, and extending to both common iliac arteries. Image 3 reveals a significant stenosis of the left superficial femoral artery, explaining the symptoms of arteritis related by the patient. Image 4 shows normal popliteal and distal arteries.
The renal artery stenosis was treated by percutaneous angioplasty, and the femoral artery stenosis was confirmed by angiography during the same procedure. The extension of the aneurysm on MRI was confirmed by subsequent surgery.

Image 5

Aortic aneurysm, renal artery stenosis, Image 1		Aortic aneurysm, renal artery stenosis, Image 2		Aortic aneurysm, renal artery stenosis, Image 3
Aortic aneurysm, renal artery stenosis, Image 4		Aortic aneurysm, renal artery stenosis, Image 5