Cardiology - Abdominal Aortic Aneurysm

Question 1

What is the normal size of the aorta in a male/female over the age of 50?

Above what size would be considered aneurysmal?

Answer 1

After the age of 50 years the normal diameter of the infrarenal aorta is 1.5cm in females and 1.7cm in males. Diameters of 3cm and greater, are considered aneurysma

Question 2

List two major risk factors for the dev elopment of aneurysms

Answer 2

smoking and hypertension

Question 3

Name a connective tissue disease that predisposes to aneurysm formation

Answer 3

Ehlers Danlos Type 1

Marfans

Question 4

Screening for AAAs?

Answer 4

A single abdominal ultrasound for males aged 65

Question 5

An asymptomatic 65 year old male is screened for a AAA. They find the aortic diameter to be 3.5cm. How should this patient be managed?

Answer 5

Rescan every 12 months, optimise cardiovascular risk factors

< 3 cm Normal - No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
>= 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients

Question 6

An asymptomatic 65 year old male is screened for a AAA. They find the aortic diameter to be 5.3cm. How should this patient be managed?

Answer 6

Rescan every 3 months
Optimise cardiovascular risk factors (smoking, exercise, weight loss)
Medical Management - Lipis - statins, aspirin, BP management

< 3 cm Normal - No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
>= 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients

Question 7

An asymptomatic 65 year old male is screened for a AAA. They find the aortic diameter to be 4.5cm. How should this patient be managed?

Answer 7

Rescan every 3 months
Optimise cardiovascular risk factors (smoking, exercise, weight loss)
Medical Management - Lipis - statins, aspirin, BP management

< 3 cm Normal - No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
>= 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients

Question 8

An asymptomatic 65 year old male is screened for a AAA. They find the aortic diameter to be 5.5cm. How should this patient be managed?

Answer 8

Refer within 2 weeks to vascular surgery for probable intervention

< 3 cm Normal - No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
>= 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients

Question 9

A 66 year old male returns for repeat scanning due to a previous finding of an asymptomatic 3.5cm AAA. They find the aortic diameter to be 5cm. How should this patient be managed?

Answer 9

Refer within 2 weeks to vascular surgery for probable intervention

A rapidly enlarging AAA (>1cm/year) should be managed as high rupture risk.

Question 10

Describe how a high risk AAA is surgically managed

Answer 10

treated with either an elective endovascular repair (EVAR) or open repair if unsuitable.
In EVAR a stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm.

Question 11

What is the mortality of a ruptured AAA

Answer 11

80%

Question 12

A patient presents with severe, central abdominal pain radiating to the back
On examination they have a pulsatile, expansile mass in the abdomen
The patients is shocked (hypotension, tachycardic). How would you manage this person?

Answer 12

• Pain Management
• Fluid resus
• Immediate vascular review with a view to emergency surgical repair

NB if patient is haemodynamically stable they may be sent for a CT angiogram.

Question 13

List some advantages and disadvantages elective endovascular repair (EVAR)

Answer 13

EVAR

• better for older patients
• less peri-operative mortality
• Reduced hospital stay
• better cosmetic outcome

However -

• no mortality benefit >5 years
• there can be later complications such as graft migration, stenosis, distant thromboembolisms.
• Not better than medical treatment in those unfit for surgery.

Question 14

What is the risk of rupture with a AAA <5.5cm?

Answer 14

a yearly risk of 1 in 100

Question 15

How would you counsel a patient on their expected hospital stay following an open AAA repair?

Answer 15

7-10 days if recovery is straightforward

Patients might spent one or two nights on a high dependency unit.

Normally Eating within 3 days

Wound should dry and largely be healed within 10 days.

Question 16

How would you counsel a patient about the recovery period following an open AAA repair?

Answer 16

around 3 months, during this time you should rest a lot, gradually increasing your activity levels.

It can take 6-12 weeks before returning to work. Particularly important if you drive for a living.

Question 17

How would you counsel a patient on their expected hospital stay following an Endovascular AAA repair?

Answer 17

After uncomplicated endovascular repair, most patients return to the hospital
ward for one to three days. You should be able to eat and drink normally once fully
awake following your aneurysm repair.

Question 18

How would you counsel a patient about the recovery period following an endovascular AAA repair?

Answer 18

Once you are up and about, you should be able to leave hospital, but may need
painkilling tablets for up to a week. It is normal to make a full recovery in about 2 weeks.
During this time, you should gradually build up your level of activity back to normal. You
may resume normal sexual relations as soon as you as you feel comfortable.

Return to work: Most people who are treated with endovascular repair can return to
work within a month after having surgery.

Question 19

What are the risk of a AAA repair

Answer 19

Normal - infection, bleeding.
• Heart attack.
• Stroke.
• Kidney failure.
• Chest problem.
• Loss of circulation in the legs or bowel.
• Infection in the graft used to replace your aorta.
• DVT
• 1/10 men suffer from erectile dysfunction