Sample template for reporting an aortic aneurysm: (Please note this is just a suggested template and any report you write has to be individualized depending on the patient’s history and findings). The template is also available on our blog on abdominal aortic aneurysms.
EXAMINATION: CTA of the thoraco-abdominal aorta
CLINICAL INDICATION: …
TECHNIQUE: Dedicated CT angiography of the thoracic and abdominal aorta was performed, covering from the cervicothoracic junction upto the common femoral arteries after intravenous administration of 100 cc of non-ionic contrast.
COMPARISON: (Mention prior CTs available for comparison if it is a follow-up/surveillance scan)
First available (baseline):
(For describing an aneurysm, include: aneurysm saccular/fusiform; extent and/or branch vessel involvement, evidence of atherosclerosis, mural thickening or calcification including branch involvement – see sample description ahead.
For describing dissection, include: level of start and end, branch vessel involvement, branch vessel origin from true or false lumen.)
Measured orthogonal dimensions on current scan:
Aortic annulus: .. mm
Aorta at sinus: .. mm
Sinotubular junction: .. mm
Midascending thoracic aorta: .. mm
Distal arch: .. mm
Proximal descending thoracic aorta (at the level of right pulmonary artery) : .. mm
Distal descending thoracic aorta (at T11-12 interspace) : .. mm
Suprerenal abdominal aorta: .. mm
Infrarenal abdominal aorta (at the level of IMA origin): .. mm
Right common iliac artery: .. mm
Right external iliac artery: .. mm
Left common iliac artery: .. mm
Left external iliac artery: .. mm
(Add a mention on any aberrant vascular anatomy such as accessory renal vessels etc, and on the presence of any atherosclerotic changes; else state that these are absent)
NON VASCULAR FINDINGS:
Abdomen and pelvis: …
For example, here is a sample description of an abdominal aortic aneurysm.
‘There is a large saccular aneurysm at D11 level arising from the anterior wall of the aorta and measuring 8.6 x 8.7 cm in size. There is peripheral thrombus within the aneurysm. The aneurysm extends for a length of 3.7 cm. The celiac artery arises from the caudal aspect of the aneurysm and shows moderate to severe stenosis at the origin with post-stenotic dilatation. The distance between the distal aneurysm and the origin of the SMA is 1 cm.’
For surveillance scan on a patient who has had endograft repair, here is a sample description.
‘There has been an endovascular repair of a thoracic aortic aneurysm.
The endograft extends from just beyond the left subclavian artery origin to the mid descending aorta.
The maximum dimension of the excluded aortic aneurysm is .. mm at the .. level.
The baseline dimensions at same location were .. mm.
There is no evidence of an endoleak, and no signs of stent migration, kinking, or thrombosis.’