Abdominal Aortic Aneurysm Orla Dunlea Neurosurgical Registrar Orla Dunlea Neurosurgical Registrar

What is it? Infrarenal >50% over normal artery diameter Retro- peritoneal Inferior Mesenteric artery sacraficed Natural history is to enlarge & rupture, unless die from other causes

What causes it?

How does it present?

Lay your hands on me Most aneurysms are picked up incidentally - either by a clever doctor or scan Take a minute to palpate your patient’s abdomen, regardless of the reason you are seeing them Even a plain abdominal x-ray (especially lateral) can be a clue with calcification outline

Feel your way General Patient laying flat with 1 pillow Pulsatile swelling in the upper abdomen Stable/in shock Pulse - regular/irregular - no delay ?Carotid bruit

Examination of AAA patient Abdomen Inspection - sternotomy scar, abdominal scar Palpate - ?tender to touch (worry) expansile/pulsatile/diameter/upper limit/side to side Groin - ?femoral pulses/femoral aneurysms Auscultate for bruit Peripheral vascular examination (popliteal aneurysm)

Size Matters How big is it? <5cm - follow up >5cm likely need intervention If <5cm but increasing in size quickly = intervention Except for women

Investigations Ultrasound Screening Initial diagnosis Relationship to renal arteries Not helpful if obese

Investigations CT If obese Planning surgery

Other investigations CTA/MRA/Angiogram Bloods including G&S & coag ECG CXR Echo PFTs

In Theatre Timeout GA Arc line Catheter NG ABs Fluids Cell saver

Layers Skin Anterior layer of rectus sheath/linea alba Rectus abdominus muscles Posterior layer of rectus sheath Transversalis fascia Extra-peritoneal fat Peritoneum Greater omentum/Stomach/transverse colon Small intestine & mesentery/pancreas/duodenum

Post operative Immediate Haemodynamics Fluid balance Pulses 1Pneumonia - 5% 2Myocardial infarction - 2-5%Myocardial infarction 3Groin infection - Less than 5% 4Graft infection - Less than 1% 5Colon ischemia - Less than 1% if elective and 15-20% if ruptured 6Renal failure related to preoperative creatinine level, intraoperative cholesterol embolization, and hypotension 7Incisional hernia % 8Bowel obstruction 9Amputation from major arterial occlusion 10Blue toe syndrome and cholesterol embolization to feet 11Impotence in males - Erectile dysfunction and retrograde ejaculation (>30%) 12Paresthesias in thighs from femoral exposure (rare) 13Lymphocele in groin - Approximately 2% 14Late graft enteric fistula 15Death % if elective and 50% if ruptured Later

EVAR 2000 Up to 10% repeat procedure Co-morbidities