AAA + Ruptured

Question 1

How do we detect AAA?

Answer 1

By either symptomatic presentation, screening or incidental findings.

Question 2

Explain AAA screening programme:

Answer 2

Abdominal US scan for all men in their 65th year. Men screened for AAA have been shown to have an approximately 50% reduction in aneurysm-related mortality

1.1% screened are diagnosed.

Question 3

Symptoms:

Answer 3

• Abdominal pain
• Back or loin pain
• Distal embolisation producing limb ischaemia
• Aortoenteric fistula

Question 4

Signs:

Answer 4

Pulsatile mass can be felt in the abdomen (above the umbilical level), and rarely, signs of retroperitoneal haemorrhage may be evident

Question 5

Differentials:

Answer 5

Renal Colic

diverticulitis

inflammatory bowel disease

irritable bowel syndrome

Question 6

Investigations:

Answer 6

Initially but USS.

CT scan with contrast (Fig. 2) is warranted when at threshold diameter of 5.5cm.

X-ray is not required as it will only show the calcification.

Question 7

Medical management:

Answer 7

Any AAA less than 5.5cm can be monitored via Duplex USS, as surgery prior to this diameter provides no survival benefit either for open repair or endovascular repair

• 3.0 – 4.4cm: yearly ultrasound
• 4.5 – 5.4cm: 3-monthly ultrasound

Medical:

• Smoking cessation (reduces rate of expansion and risk of rupture)
• Improve blood pressure control
• Commence statin and aspirin therapy
• Weight loss and increased exercise

Question 8

Surgical Managment and when?

Answer 8

Considered when >5.5cm or expanding at >1cm per year or symptomatic.

• Open repair involves a midline laparotomy or long transverse incision, exposing the aorta, and clamping the aorta proximally and the iliac arteries distally, before the segment is then removed and replaced with a prosthetic graft
• Endovascular repair involves introducing a graft via the femoral arteries and fixing the stent across the aneurysm

Question 9

What is endovascular leak?

Answer 9

incomplete seal forms around the aneurysm resulting in blood leaking around the graft.

Question 10

Types of endoleak?

Answer 10

Type 1:

• Occurs at the graft ends due to an inadequate seal, most common following thoracic aneurysm repairs;

Type 2:

• Sac filling occurs from a branch vessel, most common in AAA repairs (also termed retroleak), most resolve spontaneously

Type 3:

• Occurs through a defect in the graft fabric.

Type 4:

• Occurs through the graft fabric due to the graft porosity, often occurs intraoperative and resolves with cessation of anticoagulants

Type 5:

• Continued expansion of the aneurysm sac without any demonstrable leak on imaging (endotension)

Question 11

Main complication?

And it’s symptoms?

Answer 11

RUPTURE

Abdominal pain, back pain, syncope, or vomiting*

Haemodynamically compromised with pulsatile abdo mass and tenderness.

Question 12

Rx of rupture?

Answer 12

• Immediate high flow O2
• IV access (2x large bore cannulae)
• Urgent bloods taken (FBC, U&Es, clotting) with crossmatch for minimum 6U units.
• Transferred to the local vascular unit
• Either open or EVAR

Question 13

Mortality of AAA repair?

Answer 13

4% for open

1% EVAR