Name
ANEURYSM OF ABDOMINAL AORTA
DESCRIPTION
DETAIL
CAUSES β’ Atherosclerosis β’ Infl ammatory (5-10%) β’ Traumatic β’ Genetic predisposition (Marfan,Ehlers-Danlos) --------------------------------------------------------------------------D.D. : I Abdominal masses transmitting aortic pulse β’ Other causes of abdominal pain (e.g., peptic ulcer disease) β’ Other causes of back pain (e.g., arthritis, metastatic disease). Ultrasonography. Preferred initial diagnostic tool in suspected AAA, but is not reliable for diagnosis of rupture. . CT scans. Preferred preoperative study. Avoid contrast if patient has signifi cant renal insuffi ciency. Diagnostic for infl ammatory aneurysm. . MRI. Similar to CT and avoids contrast. MR angiography may replace arteriograms. . Aortography. Does not defi ne outside dimensions of aneurysms. Indications for aortography: . Associated renovascular hypertension . Symptoms of visceral angina . Significant iliofemoral occlusive disease . Peripheral aneurysms . Horseshoe or pelvic kidney . Prior colectomy
TYPENOTES
RISK FACTORS : Hypertension, Nicotine, COPD, Familial: siblings of patients with AAA . Males = 40% risk, Females = 15% riskCARE: . The treatment of AAA is elective repair . The prevention of RAAA is elective repair GENERAL MEASURES . Control hypertension . Treat atherosclerotic risk factors SURGICAL MEASURES . Repair when: . Rupture occurs . Size > 5.5 cm ( or > 6 cm in poor surgical risk patients) . Expansion > 0.5 cm/6 months . Symptoms occur . Poor surgical risk patients: . Class III - IV angina; LVEF < 30%; recent CHF or MI; severe valve disease . Serum creatinine > 3 mg/dL . PaO2 < 50 mmHg; FEV1< IL . Cirrhosis with ascites . Diffuse retroperitoneal fi brosis; hostile abdomen . Physiologic age > chronological age . Endovascular aneurysm repair . There are currently 3 devices approved by the FDA for marketing. Late complications of these devices continues to occur. . Long term CT surveillance is required - Adequate iliac/femoral access - Infrarenal non-aneurysmal neck length of at least 1 cm at the proximal and distal ends of the aneurysm - Morphology suitable for endovascular repair - One of the following: a diameter > 5 cm; a diameter of 4-5 cm and an increase in size by 0.5 cm in the past 6 months - Health status adequate to undergo the 2 hour plus implementation procedure PATIENT MONITORING . Hypertension control . Lipid control . Perioperative complications . MI = 5% . Renal failure = 6%, chronic dialysis = 1% . Pulmonary failure = 5-8% . Microembolism (trash foot) = 1-4% . Ischemic colitis = 0.5-1% . Wound infection = 2% . Graft infection = < 0.5% . Stroke = 0.5-1% . Paraplegia = 0.2% . Post-surgical monitoring . Anastomotic aneurysm . Graft infections . Aortoenteric fi stula . Graft limb occlusion . Additional aneurysms - thoracic, thoracoabdominal, femoral POSSIBLE COMPLICATIONS β’ Rupture β’ Associated dissection β’ Thrombosis β’ Embolization distally EXPECTED COURSE/PROGNOSIS . Usually expand over time (LaplaceΒfs Law: T( wall tension) = Pressure x Radius . Wall tension is directly related to blood pressure and the radius of the artery.) When wall tension exceeds wall tensile strength rupture occurs. . Mean expansion is 0.4 cm/year . Rupture risk is increased by . Diastolic hypertension . Tobacco use . Diameter > 6 cm . COPD . Familial history . Ruptured aneurysms . 80% die before receiving defi nitive care and 50% of the remaining die during their treatment or hospitalization
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
ULTRA SOUND WHOLE ABDOMEN - MALE, COLOR DOPPLER ABDOMINAL, COMPLETE BLOOD COUNT, CT SCAN ABDOMEN, MRI