Abdominal Aortic Aneurysm

Question 1

What is an abdominal aortic aneurysm? (AAA)

Answer 1

abnormal dilatation of the abdominal aorta greater than 3cm

Question 2

What is the increase risk of cardiac death each time an AAA grows by 8mm?

Answer 2

1.34x

Question 3

What are the risk factors for an AAA?

Answer 3

Athersclerosis, connective tissue diseases like Marfans, Ehlers Danlos, inflammatory diseases, smoking, hypertension, hyperlipidaemia, family history, male, increasing age, diabetes is a negative risk for AAA

Question 4

What are the symptoms of an AAA?

Answer 4

Asymptomatic, but can have abdominal pain, back or loin pain, distal embolisation producing limb ischaemia, aorticenteric fistula

Question 5

What will be found on an examination of an AAA?

Answer 5

Pulsatile, expansile mass, and also signs of retroperitoneal haemorrhage may be present

Question 6

What are the signs of a ruptured AAA?

Answer 6

Abdominal back or loin pain, and shock and syncope

Question 7

What year are AAA screened for?

Answer 7

65 years- goes a 50% reduction in aneurysm related mortality, will have 3-5years in surveillance before repair

Question 8

What are the differential diagnosis of an AAA?

Answer 8

Renal colic, diverticulitis, IBD, IBS, GI haemorrhage, appendicitis, ovarian torsion, ovarian rupture, splenic infarct

Question 9

What investigations would you do for an AAA?

Answer 9

Ultrasound scans and then a CT with contrast is warranted when at threshold diameter of 5.5cm

Question 10

At what size of AAA is medical management given and what is it?

Answer 10

Any AAA less than 5.5cm can be monitored by Duplex USS as surgery before this gives no survival benefit, if 3-4.4 then yearly ultrasound, if 4.5-5.4 then every 3months, should stop smoking, improve blood pressure, start statin and aspirin and lose weight

Question 11

What size AAA should surgery be considered?

Answer 11

above 5.5cm, if expanding by more than 1cm a year or symptomatic

Question 12

What are the surgical options for an AAA?

Answer 12

Open repair (midline laparotomy or long transverse incision) or endovascular repair

Question 13

What is an important complication of endovascular repairs?

Answer 13

endovascular leak

Question 14

What is an endovascular leak?

Answer 14

Where an incomplete seal forms around the aneurysm resulting in blood leaking around the graft

Question 15

What are the symptoms of an endoleak?

Answer 15

Usually asymptomatic so will need regular ultrasounds

Question 16

What can occur due to an endoleak?

Answer 16

the aneurysm can expand and rupture

Question 17

What are the complications of AAA?

Answer 17

rupture

Retroperitoneal leak. embolisation, aortoduodenal fistula

Question 18

What increases the risk of AAA rupture?

Answer 18

the diameter increase, smoking, hypertension, female

Question 19

What are the symptoms of an AAA rupture?

Answer 19

abdominal pain, back pain, syncope, vomiting, haemodynamically compromised, pulsatile abdominal mass and tenderness

Question 20

What is the classic triad of a ruptured AAA?

Answer 20

Flank or back pain, hypotension, pulsatile abdominal mass

Question 21

What has a better prognosis an AAA that ruptures anteriorly into the peritoneal cavity or posteriorly into the retroperitoneal space?

Answer 21

If rupture posteriorly into the retroperitoneal space has a better prognosis

Question 22

What is the management of a ruptured AAA?

Answer 22

immediate high flow O2, IV access (2x large bore cannulae), urgent bloods taken and crossmatch, treat shock but keep BP <100mmHg as raising BP will dislodge any clot and precipitate bleeding, theatre for open repair or a CT angiogram to check if can do an endovascular repair

Question 23

What has better outcomes Endovascular repair or open repair for an AAA?

Answer 23

no improvement at 30 or 1 year difference, but at 3 years EVAR is better due to short hospital stays, return to own homes and lower cost