aortic abdominal aneurism

Tigran Garabedyan, DOPGY3ARMC

Definition: pathological dilatation of the normal aortic lumen involving one or several segments

Fusiform -circumferential (common), Saccular- outpouching of a

segment Pseudoaneurysm: well-defined

collection of blood and connective tissue outside the vessel wall

AAA present in 2% of population Incidence is increasing 9th leading cause of death in the USA -

15,000 annually After rupture only 25% reach ED alive,

10% make it to OR alive Natural history is to enlarge and rupture Elective operative mortality-1.5% Emergent operative mortality-50% Free rupture mortality- > 90%

AAA diameter (cm) Rupture risk (%/y) <4 0 4-5 0.5-5 5-6 3-15 6-7 10-20 7-8 20-40 >8 30-50

Risk of Rupture is higher than risks associated with repair (5-5.5)

Size really does matter!

Age (M>55 y/o; F>70 y/o) Male Atherosclerosis – especially PVD Gene (Marfan, Ehlers-Danlos syndrome) Aneurisms of the femoral or popliteal Smoking- 7 fold risk, 90% OF AAA are

smokers Family history- 4 fold risk

Pain: most common, at hypogastrium or back, not affected by movement

75 % asymptomatic Rupture triad: abdominal or back pain;

palpable/ pulsatile abdominal mass; hypotension (<1/3 cases)

Bruit (+/-) Abdomianl echo, CT, MRA, aortography

Vague abdominal pain Blue toe syndrome Palpable mass Popliteal aneurism- 64% have AAA

Classic triad Acute onset abdominal and flank pain Shock Palpable abdominal mass

Additional Symptoms Death Tachycardia Diaphoresis Back pain Abdominal distention/tenderness

The USPSTF recommends: Men 65-75 year old who have ever

smoked Men and women older than 50 with a

family history Against screening women Women 60-85 year old with cardiac risk

factors

Surgical indication: rupture; size >5.5cm; expanding rapidly (>1.5 cm/year)

Coronary angiography Medication control: Hyperlipidemia,

hypertension, cigarette smoking cessation

CT follow up every 3—6 months

Surgical repair vs Endovascular repair Depends on “anatomic features of AAA

Endovascular Aneurism “neck”, relationship to renal arteries Iliac arterial size Hospital stay 2-3 days Small incision in groin Back to normal activity in about a week Yearly CT angiograms post-op

Surgical In 2010, non-endovascular candidates Younger patients Patient preference Hospital stay 5-7 days, 1-2 in ICU High mortality Big incision No yearly follow-ups post -op

Recognize AAA potential ABC’s Treat shock

Compensated Uncompensated

Drive fast

Initiate triage Index of suspicion BP management Clinical imaging

Treat like major trauma Ultrasound CAT scan

Massive resuscitation protocol Immediate operative intervention

Recognition, Recognition, Recognition Rapid transport Prompt effective treatment “Trauma mindset” Physician/facility experience & expertise Outcome measures

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Thank you!