Abdomina Aortic Aneurysm (AAA)

Question 1

What is AAA?

Answer 1

• abnormal dilatation of the abdominal aorta with a diameter greater than 3 cm

Question 2

What are the RF for AAA?

Answer 2

• Age
• Male gender
• Atherosclerotic disease
• Family history
• Smoking
• Hypertension
• Diabetes
• Connective tissue disorders (Marfan’s disease, Ehler’s Danlos, Loey Dietz)

Question 3

What are the clinical features of AAA?

Answer 3

• Asymptomatic (majority of times)
• Symptomatic if ruptures of impending rupture
• Abdominal pain
• Back/loin pain
• Hypotension
• Tachycardia
• Collapse
• Pulsatile abdominal mass

Question 4

Who is the AAA screening programme for?

Answer 4

• USS for men aged 65 and over
• women over 70 with any one of;
  
  • COPD, vascular disease, family history, hyperlipidaemia, hypertension, smoker/ex-smoker

Question 5

Describe the AAA screening program

Answer 5

• < 3cm: No further follow-up required
• 3cm - 4.4cm:
  
  • advise yearly screening with USS
  • give lifestyle advice.
  • Refer to vascular service within 12 weeks.
• 4.5cm - 5.4cm:
  
  • advise 3 monthly screening with USS,
  • give lifestyle advice
  • Refer to vascular service within 12 weeks.
• > 5.4cm:
  
  • urgent two-week wait referral to vascular surgery

Question 6

What Ix would you order for AAA?

Answer 6

Bedside

• Observations/Monitoring
• ECG
• Urine dip

Bloods

• FBC
• UE
• LFT
• Clotting screen
• ABG/VBG
• Group and Save / Crossmatch

Imaging

• Abdo USS - trace free fluid is considered normal finding (first line)
• thin-slice contrast-enhanced arterial-phase CT angiography

Question 8

How would you mx

Question 9

What is the AAA screening programme called?

Answer 9

national abdominal aortic aneurysm screening programme (NAAASP)

Question 10

What is the differential diagnosis for AAA?

Answer 10

• renal colic
• diverticulitis
• inflammatory bowel disease
• irritable bowel syndrome
• GI haemorrhage
• ovarian rupture
• splenic rupture

Question 11

How would you mx AAA in an eletive setting?

Answer 11

Conservative

• Smoking cessation
• Improve blood pressure control
• statin and aspirin therapy
• Weight loss and increased exercise

Surgery

• open surgical repair
• Endovascular Aneurysm Repair (EVAR)

Question 12

What are the indications for elective surgery?

Answer 12

• Diameter > 5.4cm
• Symptomatic aneurysms
• Asymptomatic, > 4cm and grown by more than one cm in a year.

Question 13

What is a cx of EVAR?

Answer 13

• Endovascular leak

Question 14

What are the cx of AAA?

Answer 14

• ruptured AAA
• retroperitoneal leak
• embolisation
• aortoduodenal fistula

Question 15

What increases risk of ruptured AAA?

Answer 15

• inc. diameter of aneurysm
• smoking
• hypertension
• female gender

Question 16

What is the classic triad of AAA?

Answer 16

• flank or back pain
• hypotension
• pulsatile abdominal mass

Question 17

How would you mx ruptured AAA?

Answer 17

Initial

• High flow O2
• IV access - 2 large bore cannula
• urgent bloods + crossmatch 6U
• keep the BP≤100mmHg - prevent clot dislodge
• refer to vascular unit

if Ruptured infrarenal AAA

• EVAR

if Standard EVAR unsuitable

• Open surgical repair

Question 18

Where do most triple As rupture?

Answer 18

• posteriorly into retroperitoneal space
• *presents with classic triad of
  
  • Flank pain, hypotension, abdominal mass