AbdominalAor,cAneurysm

By:NancyLiao

68‐year‐oldmalewithhistoryofsmallcelllungcancer,atrialfibrilla,on,CHF,coronaryarterydisease,COPD,AAA,andpancrea,,spresentedtotheEDbyEMSwithcomplaintsofdecreasedPOfor3daysandnausea/vomi,ng.HealsoreportsonepresyncopalepisodewhilegoingfromsiNngtostanding.EMSreportedbloodpressureat108/66onarrivalwithaheartrateof86.

Duringhisworkupanaor,cultrasoundexamwasperformedwhichdemonstratedhispreviouslyknownabdominalaor,caneurysm.

Clinicalindica,onofbedsideAortaU/Sexam

(suspectedleakingorrupturedAAA):abdominalpain,hypotension,syncope,flankpain

Aor,cLumenDiameter

Note:Aortashouldbemeasuredfromouterwalltoouterwallforevalua,onofAAA(>3.0cmisthelowerlimitforAAA)

LongitudinalViewofAAA

TransverseViewofAAA

LumenofAorta

Aneurysm

TransverseViewofAAA

LumenofAorta

Aneurysm

TransverseViewofAAA

LumenofAorta

Aneurysm

OverviewofAAA

Aneurysm:involvesallthreelayersofaorta‐in,ma,media,andadven,,a

>3.0cmdiameter,measuredfromouterwalltoouterwall

Normaldiameteris<2.3cminmenand<1.9cminwomen.Diametermayincreasewithage.

Strongassocia,onwithatherosclerosis

Presenta,on

•  Maybeasymptoma,cun,lexpansionorrupture– Suddenandsevereabdominal,back,flank,orgroinpain

– Syncope–  rupturedAAAo]enpresentsasshockas:hypotension,,tachycardia,andalteredmentalstatus.>65%ofpa,entswithrupturedAAAdiefromsuddencardiovascularcollapse

RiskofRupture

•  Diameterofaneurysmisdirectlycorrelatedwithriskofrupture

•  substan,alincreaseinruptureriskasAAAdiameterincreasesfrom5cmto6cm

•  Independentpredictorsofrupture:historyofsmoking,increasedini,aldiameter,COPD,andhypertension.

•  Womenhavehigherratesofruptureatsmallerdiameters.

Guidelinesforthetreatmentofabdominalaor,caneurysms:ReportofasubcommideeoftheJointCounciloftheAmericanAssocia,onforVascularSurgeryandSocietyforVascularSurgeryDavidC.Brewstera,JackL.Cronenwed,JohnW.Halled,K.WayneJohnston,WilliamC.Krupski,JonS.Matsumura;JournalofVascularSurgery;May2003(Vol.37,Issue5,Pages1106‐1117)

SurgicalTreatment•  5.5cmisthresholdforrepairinmostpa,ents,unlessrapidexpansion(>0.5cm/year)orpa,entsbecomesymptoma,c

•  Elec,veinterven,onat4.5cmto5.0cmisindicatedinwomen.

•  Endovascularrepair(EVAR)vs.standardopenrepair– EVAR‐lowermortalityandmorbiditybutalsowithhigherlatecomplica,onsandreinterven,onrates

Guidelinesforthetreatmentofabdominalaor,caneurysms:ReportofasubcommideeoftheJointCounciloftheAmericanAssocia,onforVascularSurgeryandSocietyforVascularSurgeryDavidC.Brewstera,JackL.Cronenwed,JohnW.Halled,K.WayneJohnston,WilliamC.Krupski,JonS.Matsumura;JournalofVascularSurgery;May2003(Vol.37,Issue5,Pages1106‐1117)

MedicalManagement

•  Riskfactormodifica,on–  Smokingcessa,on– Hypertensivemanagement‐Betablockers– Hypercholesterolemiamanagement‐HMG‐CoAreductaseinhibitor(sta,ns)

•  Followup– AAA>4.0cmshouldbemonitoredforrapidexpansion(>0.5cm/year)oranincreaseinsizeto5.5cmorlarger

– U/Sinterroga,onorCTscanningevery6months

Pa,ent’shospitalcourse

Presyncope‐Thepa,entwasfoundtobeorthosta,cbyvitalsigns.HewasgivenIVfluidhydra,onandhadresolu,onofsymptoms.Cardiovascularworkupincluded:nega,veserialtroponins,normalAICDinterroga,on,andstableAAA(whichcon,nuedtobemedicallymanaged)

Intraventricularhemorrhage‐NoncontrastheadCTthatshowedanintraventricularhemorrhageinboththerightandle]lateralventricles,R>L.RepeatCTx2didnotshowanyprogressionofhemorrhage.Hedidnotdevelopanyfocalneurologicalchanges.Aspirin/Plavixwereheld.

Thepa,entwasdischargedonhomemedica,ons(exceptaspirinandPlavix)andwithhomenursingtoprovideintravenoushydra,onasneeded.