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© 2018 EDIZIONI MINERVA MEDICA International Angiology 2019 February;38(1):39-45

Online version at http://www.minervamedica.it DOI: 10.23736/S0392-9590.18.04006-3

ORIGINAL ARTICLE ITOR

AORTIC DISEASE

ED

’S
H

E
OIC

Effect of intraluminal thrombus on growth rate

of abdominal aortic aneurysms
Andrej DOMONKOS 1 *, Robert STAFFA 1, 2, Luboš KUBÍČEK 1, 2

1Faculty of Medicine, Masaryk University, Brno, Czech Republic; 2Second Department of Surgery, Center for Vascular
Disease, St. Anne’s University Hospital and Faculty of Medicine, Brno, Czech Republic
*Corresponding author: Andrej Domonkos, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00, Brno, Czech Republic.
E-mail: domonkos.andrej@gmail.com

ABSTRACT
Background:  Abdominal aortic aneurysm (AAA) includes a variety of morphologies with changing properties.
Growth rate is one of the most important factors directly linked to the risk of rupture. Intraluminal thrombus
(ILT) covering aortic wall is found in the majority of AAAs. Yet, its role in biomechanical processes in AAA
remains unclear. From one point of view ILT can serve as protective factor in reducing wall stress of AAA
and thus slow down the growth. Modern concept of multilayered ILT proved active inflammatory processes
inside, that can significantly affect the quality of the wall and thus lead to a higher growth rate and higher risk
of rupture. The goal of this study was to analyze the effect of ILT on growth rate of AAA and support one of
these theories.
Methods: Retrospective study of computed tomography angiography scans of AAA of 26 patients was
performed. Forty pairs of consecutive scans have been analyzed. Periods between two scans varied. Maximal
infrarenal diameter of AAA and size of ILT were measured. AAAs were split into 4 groups according to their
initial diameter. Growth rate was calculated for each AAA and linked to the relative size of ILT. These values
were statistically evaluated.
Results:  Negative correlation between relative size of ILT and growth rate was found (P=0.042062). This
significant result proved that thicker thrombus slowed down the growth of AAA and vice versa, smaller relative
size of ILT was linked to higher growth rate.
Conclusions:  This finding shows importance of ILT as one of the key factors influencing biomechanical
processes inside an AAA. Results of this study may contribute to future researches of this topic.
(Cite this article as: Domonkos A, Staffa R, Kubíček L. Effect of intraluminal thrombus on growth rate of ab-
dominal aortic aneurysms. Int Angiol 2019;38:39-45. DOI: 10.23736/S0392-9590.18.04006-3)
Key words:  Aortic aneurysm, abdominal - Thrombosis - Computed tomography angiography.

Vol. 38 - No. 1 International Angiology 39

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DOMONKOS EFFECT OF ILT ON GROWTH RATE OF AAA
A bdominal aortic aneurysm (AAA) is defined as a
dilatation of abdominal aortic diameter of 3.0 cm or
more.1-3 Other studies suggest defining AAA as the maxi-
mum infrarenal aortic diameter being at least 1.5 times
larger than a diameter of unaltered part of abdominal
aorta.4 Considering AAA epidemiology, males are at 4 to
5-time higher risk than women. Other important factors
are hypertension, genetic predisposition, inflammation,
smoking, and age.5, 6 White male smokers of age over 50
are at a prevalence of 5.9%.7 In the majority of the cases,
AAA is an asymptomatic pathology. The most danger-
ous event that can occur, is its rupture, with a mortality of
30-50%, even if patient receives urgent treatment in spe-
cialized center. Otherwise ruptured AAA leads to almost
certain death.8 Risk of rupture is directly correlated with
diameter of AAA. Larger aneurysm diameter is a signifi-
cant and independent risk factor for AAA rupture.9, 10
The growth rate is a very important factor in predict-
ing risk of future rupture. Mean population data suggest,
that AAA grows at an average rate between 2.5 to 7.9
mm/year.11 These numbers may vary, even some portion
of AAAs can stay stable (11-58%).12 Dilatation of the
abdominal aorta is caused by mechanical hemodynamic
forces. When they exceed the wall strength of aneurysm,
growth continues.13 Wall quality and possible local dam-
ages play huge role in growing of AAA.
Intraluminal thrombus (ILT) covers the wall of AAA in
70% to 80% of the cases.14 The majority of all diagnosed
AAAs have ILT of variable size and overall layout. In the
majority of cases ILT is located in the most dilated portion
of the aorta, thus does not have any significant influence
on the dynamics of the blood flow (original lumen of aorta
remains patent).15 Site of rupture of AAA can be localized
in the thrombus covered portion of the wall. Studies sug-
gest, that rupture in the wall underlying the thrombus can
occur in approximately 50% of the cases.16 If a fissure oc-
curs inside ILT, direct bleeding into it can lead to immedi-
ate rupture. Bleeding into ILT was observed significantly
more frequently in ruptured than in intact aneurysms of the
same size.16
The current concept divides ILT into three layers — lu-
minal, medial and abluminar.17 Luminal layer is widely
viewed as the most resistant, consisted of fibrin, leuko-
cytes and erythrocytes. Abluminal layer (in contact with
aortic wall) is associated with high protease activity.18
The exact role of ILT in the growth of AAA is still con-
troversial. Mechanical view of this topic describes ILT as
a protective layer that absorbs part of the radial force of
blood pressure.19 This concept believes in the protective
40 International Angiology February 2019
role of the ILT — reducing wall stress slows down the
growth rate of AAA. Even more specific approach regards
the amount and individual configuration of ILT in affect-
ing the magnitude and distribution pattern of wall stress
in AAA.20 More recent concept of ILT focuses on active
inflammation process in ILT. Layers of thrombus can pro-
mote focal hypoxia in the vessel wall and weaken it.17 The
system of canaliculi within ILT can transport molecules
that induce the growth of AAA, as it was seen in animal
models.21 These concepts offer opposite answers on the
basic question of this study — how does ILT affect growth
rate of AAA. The aim of this study was to compare these
two theories and validate the role of ILT in AAA.
Risk of rupture is the most important clinical result re-
garding AAA. Growth rate is directly connected to the di-
ameter and thus to the risk of the rupture. Understanding
the expansion process of AAA can lead to better under-
standing of this topic. We were working with the hypothe-
sis that ILT is directly affecting the growth rate of AAA. If
ILT plays important role in growth of AAA future research
can alter the view of this topic.
Materials and methods
The aim of this study was to approach the topic of ILT in-
fluence in AAA growth rate from the clinical point of view.
Measuring of important variables gathered from comput-
ed tomography (CT) angiography scans was the primary
method used. This research was a retrospective study of
patients’ data who were under long-term surveillance in
our clinic.
Twenty-six patients diagnosed with AAA were included
in this study. These patients had growing AAA without any
signs of rupture. Sample of patients was under surveillance
between October 2003 and January 2018. Each patient in-
cluded has undergone CT angiography at least twice. Peri-
ods between two consecutive scans varied from 2 months
to 129 months. Average period between two scans was 24
months. One patient had undergone 3 CT scans, two had un-
dergone 4 CT scans and one patient underwent 6 CT scans.
In total we compared 40 consecutive CT scans. Scans
were analyzed by using TomoCon® PACS (Tatramed s.r.o.,
Bratislava, Slovakia). This program allowed measuring of
AAA diameter, length and surface with its native tools.
Each AAA and its ILT were measured by its length and
width. Describing a complex shape of AAA is very com-
plicated task. While trying to represent various formations
of ILT, two main parts of AAA were chosen - plane of
maximal diameter of AAA and plane of maximal size of
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EFFECT OF ILT ON GROWTH RATE OF AAA DOMONKOS
Absolute size of ILT
Absolute diameter of AAA
Figure 1.—Measurements in the plane of maximal infrarenal diameter
of AAA.
Relative size of ILT
Diameter of AAA
Figure 2.—Illustration of relative size of ILT according to diameter of
AAA.
ILT. Maximal diameter of AAA and diameter of ILT was
measured in the first plane (Figure 1). The same procedure
was done in plane of maximal size of ILT. All of the mea-
surements were done in millimeters to stay as accurate as
possible.
Apart from width of AAA and ILT, surface of AAA and
ILT were covered in each part. These measurements were
done with TomoCon® tool for measuring surface. Work-
ing in two-dimensional field of CT scan offered possibility
to approach relative size of ILT from other perspective.
Length of AAA and its ILT was also measured from CT
images. CT angiography scans we used, were done in gaps
of 5 mm. This measurement served as proof of examina-
tion of whole AAA, not just its parts.
Vol. 38 - No. 1 International Angiology 41
The time between two consecutive CT scans was cal-
culated. Widths the AAA was measured in the same plane
in both first and second CT scan and data were compared
to estimate the growth rate of each AAA. The growth rate
was calculated in widely accepted unit millimeters per
year. Each growth rate was associated with size of ILT. In
order to homogenize the sample of varying diameters and
thus varying sizes of ILT, relative size of ILT according to
diameter of AAA was calculated. The diameter of AAA
and the width of ILT were used to estimate the relative size
of ILT (Figure 2).
These calculations were made for both points estimated
in our measurements (plane of maximal diameter of AAA
and plane maximal size of ILT). To compare growth rate
and associated value representing ILT, Pearson correlation
coefficient was used.
In order to minimize the effect of faster growth in larger
AAA,6 AAAs were divided by maximal infrarenal diam-
eter and 4 artificial groups were created. These groups
included AAA with the range of diameters. Each group
included range of 10 mm. 4 groups were created: group 1
from 30 mm to 39.99 mm, group 2 from 40 mm to 49.99
mm, group 3 from 50 mm to 59.99 mm, group 4 from 60
mm to 69.99 mm. Group 1 included 9 patients, group 2 in-
cluded 12 patients, group 3 included 3 patients and group
4 included 4 patients. For each group average growth rate
in millimeters per year was calculated.
Results
Forty comparisons of consecutive CT angiography scans
of abdominal aorta were analyzed. Each comparison was
done between two scans. Average time between scans
were 24.31±23.38 months.
First set of comparisons was done in plane of maximal
diameter of AAA. The first scan was representing start-
ing point and second scan was the end point of growing
AAA. Two scans were compared to calculate growth rate
(standardly in millimeters per year). Average maximal di-
ameter of AAA in the first of two consecutive scans (start-
ing point) was 49.16±10.13 mm. Average diameter in the
second scan (end point) was 56.64±13.45 mm. Average
growth rate through the whole set of analyzed AAAs was
4.48±3.89 mm per year.
Second set of comparisons was done in plane of maxi-
mal size of ILT. Average diameter in the starting point of
AAA was 47.68±9.44 mm. Average diameter in the end
point was 55.41±12.59 mm. Average growth rate in this
plane was 4.43±3.98 mm per year.
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DOMONKOS EFFECT OF ILT ON GROWTH RATE OF AAA

Apart from transverse view of AAA, frontal plane in each

6
case was analyzed. Average length of AAA was 86.10±25.34
mm. Average length of ILT was 76.27±29.07 mm. These
Growth rate (mm per year)

5.5
Group 3 Group 4
values represent varying morphology of each AAA and
heavily depend on individual anatomy of each patient.
5

Growth rate according to maximal diameter

4.5 Group 2
Group 1 In order to fully understand basic growth mechanism of
AAA groups were created according to maximal diam-
4
eter. Each group included a range of maximal infrarenal
3.5
diameters. Average growth rate in millimeters per year
(30-39.99) (40-49.99) (50-59.99) (60-69.99) was calculated for each group (Table I). Group 1 had the
Group range (mm) slowest average growth rate 3.85 mm per year, whereas
group 4 had the highest one with 5.87 mm per year. Aver-
Figure 3.—Correlation between increased growth rate and maximal in- age growth rate was increasing with the maximal infrare-
frarenal diameter.
nal diameter (Figure 3).
Growth rate according to relative size of ILT
9.5 Average absolute size of ILT in the first set of CT scans
8.5 was 16.11±8.73 mm. We believe that absolute size of ILT
Growth rate (mm per year)

7.5 cannot represent the actual morphology of AAA. Large

6.5 aneurysm with only thin ILT and vice versa small aneu-
5.5 rysm with thick thrombus cannot be compared by absolute
4.5 size of ILT. Therefore, relative size of ILT was calculated.
3.5 Absolute diameter of AAA in its widest point (plane of
2.5 maximal diameter of AAA) and absolute size of ILT was
1.5 compared. Average relative size of ILT was 33.28±16.95%.
0.5 Relative size of ILT from the first scan and average
5% 15% 25% 35% 45% 55%
growth rate per year were compared. These two set of data
Relative size of ILT
did correlate. Negative correlation between size of throm-
Figure 4.—Linear correlation between relative size of ILT and growth bus and growth rate was found. Pearson correlation coef-
rate in plane of maximal infrarenal diameter.
ficient in our set was r=-0.324. This result is significant at
P<0.05 (P=0.042062) (Figure 4).
The same procedure was done in the second plane of
9.5 our measurements, plane of AAA with maximal size of
8.5 ILT. Average relative size of ILT was 36.88±16.36%. Pear-
Growth rate (mm per year)

7.5 son correlation coefficient was r=-0.230968027. Although

6.5 negative correlation was found, this result has not been
5.5 proven significant (Figure 5).
4.5

3.5
Table I.—Groups of AAAs sorted by maximal infrarenal diam-
2.5 eter.
1.5
Size range of maximal
Group number Growth rate (mm per year)
0.5 infrarenal diameter (mm)
5% 15% 25% 35% 45% 55%
1 30-39.99 3.86
Relative size of ILT 2 40-49.99 4.81
3 50-59.99 4.95
Figure 5.—Linear correlation between relative size of ILT and growth
4 60-69.99 5.87
rate in plane of maximal size of ILT.

42 International Angiology February 2019

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EFFECT OF ILT ON GROWTH RATE OF AAA DOMONKOS
Growth rate according to surface
Average surface of AAA in point of maximal diameter in
the first set of CT scans was 19.31±8.49 mm2. Average
surface of ILT was 9.06±8.29 mm2. Relative surface of
ILT (in comparison to the absolute surface of AAA) was
44.84±23.52%. With these values we were able to calcu-
late absolute and relative surface of the aneurysm without
ILT (i.e. surface of blood flow). Absolute surface of blood-
flow was 10.24±5.68 mm2. Relative surface of bloodflow
was estimated at 55.16±23.52%. No correlation was found
between surface of ILT or the blood flow and growth rate
of AAA.
Discussion
We worked with data collected through years 2013-2018
and used at least two consecutive CT angiography scans
from each patient. Time between two scans varied mainly
due to individuality of each case. Consecutive CT scans
were done with irregular frequency. Shortest period be-
tween 2 scans was 2 months, the longest period was almost
11 years. Average time between scans was 24 months. In
order to homogenize the sample, we calculated average
growth rate in millimeters per year. Some patients had
not come for planned CT scan, others had other diagnosis
that were more urgent at the time. Our study included also
AAAs that were bigger than 5.5 cm (the threshold for sur-
gery).22 One patient had declined, others were not able to
undergo open surgery nor endovascular intervention due to
high risk comorbidities (mainly malignity). Primary goal
in searching data was to find AAAs that had multiple CT
scans. Due to the fact that most of our patients with maxi-
mal AAA diameter bigger than 5.5 cm would pass only
one CT examination, it was uneasy to collect sample large
enough to deliver significant results. Patients with AAA
smaller than 5.5 cm would always undergo second CT
scan after 6 months from the first one in order to estimate
growth rate and possibly intervene on rapid growing an-
eurysm (AAA with growth rate over 5 mm in 6 months).22
AAAs with diameter larger than 5.5 cm are considered to
undergo an intervention.
Average growth rate of our sample matches values de-
scribed in the literature sources. Analyzing 4 groups di-
vided by size of AAA we found correlation between maxi-
mal infrarenal diameter and growth rate. Larger diameter
associated with higher growth has been reported in other
studies.23-25
Morphology of our aneurysms did vary. This was caused
by wide sample of diameters. Average length of AAA may
Vol. 38 - No. 1 International Angiology 43
have been biased by the varying position of each patient.
Not all the scans could provide the exact reconstruction of
aorta in axial plane. In 100% of the cases, ILT was found.
Majority of AAAs do have an ILT of various morphology.
In our sample, ILT was most often found in the neck of
AAA and its size did vary mainly due to the diameter of
each part of AAA. ILT did cover nearly whole length of
AAA and in some cases covered one or both of iliac arter-
ies. Differences in initial ILT diameter were find in each
individual case of AAA. Although 4 groups represented
different starting diameters, initial morphology of ILT was
varying in each AAA. It is not possible to predict size or
shape of ILT according to maximal infrarenal diameter of
AAA. Mean population data suggest, that ILT is found in
majority of AAAs.14 It was proven to play important role
in biomechanics of aneurysms. We believe that following
results contributes to this statement.
At the beginning of the study we posed a very sim-
ple question. How does ILT affect growth rate of AAA?
Sometimes the simplest questions have very complicated
answers. To represent varying morphology of aneurysms
we have chosen to work with CT angiography scans. Us-
ing two vertical scans, we have calculated average growth
rate for each pair of AAAs. We used millimeters per year
to represent sheer speed of expansion. To homogenize our
sample we used relative size of ILT in vertical plane.
Using method of calculating surface of ILT in vertical
plane had not proven itself in being accurate enough to
produce any significant results. Surface of measured ob-
jects does not correlate with growth rate in any case and it
should not be used in this specific case. Two dimensional
CT scans had best accuracy while measuring length, com-
puting the surface did not represent the exact morphol-
ogy of AAA nor ILT in a single plane. We believe that
this method of representing correlation between ILT and
growth rate is not suitable for future research.
The plane of maximal diameter of AAA was (in our
study) proven to have the highest growth rate. In minority
of the cases, plane of maximal size of ILT did not corre-
spond with the plane of maximal diameter. Nevertheless,
diameter of AAA in both of these planes grew in negative
correlation with the size of ILT. Plane of maximal diameter
was the one of truly representing the total growth rate of
AAA, the most important value for us. In this plane ILT
had shown significant statistical value. We used Pearson
correlation coefficient in order to support our findings. We
were comparing absolute growth rate of AAA with relative
size of ILT. The covariance of these two variables proved
to be a linear correlation. From our heterogenous sample
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DOMONKOS EFFECT OF ILT ON GROWTH RATE OF AAA
of AAAs of various sizes and morphology, we can claim
that growth rate in maximal diameter had been influenced
by the size of ILT.
This result stands in between of two views of this topic
as is mentioned in the literature. Inflammatory activity in
ILT can degrade the quality of the aortic wall and reduce its
resistance against the hemodynamic forces. ILT modify the
wall stress and strength as it has been proven before.26-29
Simplified mechanical view of ILT as protective layer over
the wall, on the other hand, states that thrombus can serve
as a protective factor in reducing wall stress.19 Acknowl-
edging both of these views, we cannot accept one and com-
pletely deny the other. Findings of both approaches should
be considered in the modern understanding of this topic.20
Limitations of the study
Results of our research are limited by the size of our sam-
ple. Patients who underwent CT angiography scans with
suspected AAA did not have measured blood pressure im-
mediately before the CT examination in their medical re-
cords. Thus, we were not able to include blood pressure as
one of the main factors influencing the growth rate and the
risk of rupture of AAA. These findings induced custom-
ization of our AAA protocol to routinely the blood pres-
sure before each CT angiography scan performed in patient
with suspected AAA. To represent growth of AAA we have
chosen growth in its specific part. We found highest growth
rate in the plane of maximal diameter. This led us to calcu-
late the relative size of ILT and finding specific correlation.
The results of this study suggest that ILT may serve as
a protective factor in question of sheer growth of AAA in
its maximal diameter. Our findings indicate that AAA with
smaller thrombus will grow faster than AAA with the big-
ger one. These clinical findings may be confronted with
mathematical calculations in order to fully understand bio-
mechanical processes in AAA. This can be done by using
FE (finite element) modeling and furthermore biomechani-
cal indices like PWS (peak wall stress) and PWRR (peak
wall rupture risk).30 Future research of this topic is needed
to bring significant results that can alter the view of ILT in
AAA.
Conclusions
This paper is meant to represent a different approach to
the topic of ILT in AAA. Main conclusion of this study
is significance of ILT in very complex subject of AAA
growth rate. In our sample we have proven that ILT plays a
significant role in growth of AAA. We found a significant
44 International Angiology February 2019
negative correlation between the relative size of ILT and
the growth rate of AAA. Of course, thrombus is not the
only element influencing growth rate. Nevertheless many
articles that have been published in the literature manifest
that its significance is unquestionable. We believe that
such complex topic as AAA, cannot be viewed only by
the maximal diameter. Numerous factors play a role ei-
ther in its growth or the rupture risk and ILT is surely one
of them. All the scientific findings regarding the topic of
ILT should be taken into consideration before deciding on
one unanimous answer of its role. Future research in this
topic is needed to be done in order to fully understand all
mechanical and biological processes affecting AAA. Bet-
ter understanding of this pathology can lead to personal
approach to each diagnose and it can offer individual treat-
ment options for the patients.
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manu-
script.
Authors’ contributions.—Robert Staffa and Luboš Kubíček conceived the presented idea; Andrej Domonkos developed the theory and performed the
computations; Luboš Kubíček verified the analytical methods. All authors discussed the results and contributed to the final manuscript.
Article first published online: November 7, 2018. - Manuscript accepted: October 29, 2018. - Manuscript received: April 5, 2018.

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