Epidemiology, Risk Factors, Diagnosis and Intervention of Abdominal Aortic Aneurysms By, Sultan O Al-Sheikh

Epidemiology  per 100,000  Elderly White Men 3.5 per 1000 person-years in UK  M:F  W:B  Delayed onset in women  Incidence increased with the use of US, CT scan & MRI

Risk Factors  Smoking is almost universal for young adult with AAA while 23% of them have Marfan’s syndrome  Veteran administration screening study >73,000 patients aged 50 to 79 years  The prevalence of >3cm AAAs was 4.6% while >4.6cm AAAs 1.4%

VA Screening Study  Gender  Smoking  Age  Family Hx  Race  HTN  CAD  High cholesterol  PAD  COPD  Height  DM

Clinical Presentation  Feeling of Pulse in the abdomen  Pulsatile mass in a routine physical  Present as a complication

Most common presentation

Rupture  Causes abrupt pain, tachycardia and stress  Can persist up to weeks without hypotension  HTN increases the risk of rupture  Median age for rupture 76 in men & 81 in women with a median size of 8 cm

 78% Mortality & three-fourth rupture outside the hospital  20% bleeds anteriorly  80% bleeds posteriorly

 Thrombosis Rare Cause Catastrophic Ischemia  Embolism More common Considered in pt without atherosclerotic occlusive disease  Both combined occur in less than 2-5 %

Diagnosis  Clinical presentation Pain Hypotension Tachycardia Ischemia

US

CT

MRI

Arteriography

Intervention  Screening Early stage Improve the outcome Inexpensive Accurate Low risk Cause effective No or little pain

Medical Management  Periodic size measurements  Smoking cessation  Aggressive control of hypertension  Doxycycline

Surgical Treatments  Endaneurysmorrhaphy with intra luminal graft placement  Laparoscopy with minilaparotomy  Endovascular repair reduces operative mortality, morbidity, length of stay and disability after surgery Lifelong surveillance?

 Transverse Trans peritoneal Approach More time to open & close Fewer pulmonary complications & late incisional hernia

 Retro peritoneal Approach Good exposure of infra & supra renal aorta Limit exposure of contra lateral & iliac arteries Doesn’t allow access to other intra abdominal organs Left side is preferable over the right side

 The choice between observation and prophylactic surgical repair should take into account The rupture risk under observation Operative risk of repair Life expectancy Personal preference of the patient

Other options  Endovascular repair  Delay or avoid AAA repair  Perform repair with extensive cardiac monitoring & management  Reducing cardiac risk with coronary bypass graft, angioplasty or stenting had no randomized trial

Complications  MI  MSOF  Pneumonia  Iatrogenic injuries  Colon ischemia  Distal immobilization  Venous thrombo embolism  Anastomotic disruption  Graft infection  Aorto enteric fistula

Special consideration  Supra renal aneurysm  Inflammatory abdominal aortic aneurysm  Infected abdominal aortic aneurysm Most Common are Salmonella & Staph A  Aorto caval fistulae  Primary aorto enteric fistula  Developmental anomalies  Associated abdominal disease

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