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

2. Epidemiology  3-117 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

3. 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%

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

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

6. Most common presentation

8. 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

10.  78% Mortality & three-fourth rupture outside the hospital  20% bleeds anteriorly  80% bleeds posteriorly

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

13. Diagnosis  Clinical presentation Pain Hypotension Tachycardia Ischemia

14. US

15. CT

16. MRI

17. Arteriography

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

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

20. 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?

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

22.  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

23.  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

24. 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

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

26. 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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