Inflammatory Abdominal Aortic Aneurysm with Obstructive Nephropathy in a 71 yr old Male By Chijioke Chinaka

T/F a peripheral Hospital HS, 71 yr Old Male Background Hypertension Asthma T/F a peripheral Hospital Incidental finding of 10cm Non leaking AAA On treatment for PE Presentation Left upper leg pain Swelling Cellulitis on the foot Abdominal pain0, back pain0, urinary symptoms0 Examination/investigations Swollen tender upper left leg; Duplex scan LIF mass; CT

CT SCAN Inflammatory Aneurysm Hydronephrosis Over Distended Bladder Bilateral thrombo ilio-femoral veinous system

Hydronephosis Over distended blader

Thrombosed ilio femoral venous system

Sagittal section

Examination Investigation Pulse 90b/min BP 120/80 mmHg Left Lower limb Mildly swollen Groin tenderness Cellulitic dorsum of foot Abdomen Soft Non tender pulsatile mass Investigation Bloods: Cr – 140 mmol/l, Urea – 4.1 mmol/l, CRP – 71, ESR – 42mm/hr, WCC – 8.78, Hb – 11.6

Impression - Inflammatory Aneurysm Issues Non Ruptured massive AAA Bilateral Hydroureter Poor Renal Function Plan Urology consult Nephrology consult Work up for optimization Urgent surgery

Nephrology Urology Continue protective measures N-acetyl cysteine Fluids Urology Hydronephrosis 20 ?Bladder outlet obstruction USS PSA

USS PSA Bladder not trabeculated Prostate not enlarged Kidney Right 9.7cm Left 9.5cm Right Hydronephorosis No evidence of left hydronephrosis PSA Total PSA 2ng/ml Free PSA 0.5ng/ml Ratio 25%

Cr - 105, Echo – EF 50%, Surgery (2 options) Open Repair Complicated Difficult access Fistulation Endovascular Stenting (EVAR) Suitability Minimal access

EVAR(surgery) Post Op 6th Day Aorto – iliac + Fem - Fem cross over Resolved left hydronephrosis Persistent right

DISCUSION

Inflammatory Abdominal Aortic Aneurysm

Definition Incidence Aetiology A distinct sub group of AAA exuberant inflammatory reaction marked peri-aneurysmal and retroperitoneal fibrosis dense adhesions of adjacent abdominal organs Incidence 5% to 10% of all AAA > Male (M:F = 30:1 to 6:1) Mean Age; 62 to 68 yrs Smokers 77% to 100% Aetiology Unknown >90% Genetic factor (HLA –DR B1 locus) + ve FHx (17%) Unlikely infective aetiology : Chlamydia pneumoniae. ?variant of retroperitoneal fibrosis. Walker et al. Br J Surg 1972;59: 609 -14, T. Tang et al EJVES Vol 29 Issue 4, 2005; SS Nitecki et al J Vasc Surg 23 (1996) (5), pp. 860–868.

Pathophysiology Presentation Inflammation Infection Symptoms Inflammatory cell infiltrate Both in IAAA and non – IAAA but > in the later Macrophages, T- lymphocytes and B- lymphocytes Immune Response Infection Herpes simplex and Cytomegalovirus Chlamydia pneumonia Presentation Symptoms Usually symptomatic (80%) Abdominal pain + back pain Weight loss Asymptomatic (20%) A. Stella et al Ann Vasc Surg 7 (1993), pp. 229–238.

Diagnosis Signs Others CT Scan Ultrasound Scan MRI Nuclear Medicine Tender pulsatile abdominal mass (15% to 30%) Elevated ESR (40% to 88%) Raised CRP Auria (Rare) Others Ischaemic foot Intermitent claudication Diagnosis CT Scan Sensitivity 83.3% Specificity 99.7% Overall accuracy 93.7% Ultrasound Scan MRI Nuclear Medicine

Inflammatory AAA Atherosclerotic AAA Younger patient Usually symptomatic Elevated inflammatory maker Marked thickening of Aneurysmal wall Fibrosis of Adjacent retroperitoneun Less likely to rupture Strongly related to smoking Older patient Usually asymptomatic Unrelated Less thickening of wall Less fibrosis More likely to rupture

Treatment Non Operative Operative Extensive fibrosis Steroid therapy Risk of Rupture Operative Open Surgery High technical difficulty Increased morbidity/mortality rate Longer operating time Longer hospital stay EVAR Longer-term peri aneurysmal regression Uretrolysis/Management of Related Pathology