Abdominal aortic aneurysm resident survival guide

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Abdominal aortic aneurysm Resident Survival Guide Microchapters
Overview
Causes
Screening
Treatment
Ruptured Aneurysms
Asymptomatic Aneurysms
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2]

Synonyms and Keywords: Approach to abdominal aortic aneurysm; Abdominal aortic aneurysm workup; Abdominal aortic aneurysm screening algorithm

Overview

Abdominal aortic aneurysm (AAAs) are defined as abnormal dilation of abdominal aorta, mostly in the infrarenal part of aorta with extension to iliac arteries, up to more than 3 cm in the greatest diameter or dilatation of more than 50% of its diameter. Aneurysms are related to regional weakening of the vessels wall structure. Although AAAs are more common in men than women, women with AAAs have worse prognosis than men. The predisposing factors include male gender, age >75 years, prior vascular disease, hypertension, smoking, family history of cardiovascular disease and hypercholesterolemia. The incidence of AAAs has continued to rise, of which they remain the leading cause of death in USA. The majority of AAA cases are usually asymptomatic and detected accidentally. Unruptured aneurysms may present mild abdominal or back pain with pulsatile mass while ruptured aneurysms cause severe abdominal or back pain, hypotension and shock and they are associated with high mortality. AAAs are attributed to primary and secondary aneurysm. Primary aneurysms relate to defects in vessel wall (i.e. fibrillin deficiency or collagen III deficiency). Secondary aneurysms relate to turnover and pathological vessel wall remodeling. Imaging is vital for detection of AAAs. Abdominal X-ray and ultrasound are performed to detect AAAs.Ultrasound is simple, safe and inexpensive with sensitivity of 95% and specificity close to 100%. CT angiography is another imaging option which is the gold standard in evaluation of aortic size and extension of aneurysm, though it has high radiation doses.

Causes

Life Threatening Causes

Acute ruptured AAAs are surgical emergencies and if left untreated, it has a mortality rate approaching 100%.

Common Causes

Screening

Screening of abdominal aortic aneurysm is identifying people who are at risk of AAAs. The method of screening for AAA is abdominal ultrasonography and must be performed in the following individuals:[2][3]

The table below provides the indication of AAA screening based on various society guidelines:

SVS ACPM/CSVS ESVS USPSTF NHS ACC/AHA
  • Men[6]
    65 years
    <65 years if at increased risk (smoke, cardiovascular disease) or family history
  • Women
    Do not screen
    Need more research in older female smokers
  • Men[7]
    65 to 75 years who ever smoked
  • Women
    65 to 75 years who ever smoked
  • Men
    65 years
  • Women
    70 and over who already have risk factors
  • Men[8]
    65-75 years who ever smoked
    60 years with family history
  • Women
    Do not screen

Abbreviations: SVS:Society for Vascular Surgery; ACPM:American College of Preventive Medicine; CSVS:Canadian Society for Vascular Surgery; ESVS:European Society for Vascular Surgery; USPTF:U.S. Preventive Task Force; NHS:National Health Society; AHA:American Heart Association; ACC:American College of Cardiology

Treatment

Ruptured Abdominal Aortic Aneurysms (rAAA)

[9]
 
 
 
 
 
 
 
Patient with suspected rAAA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamically stable (systolic BP > 80mm Hg)
 
 
 
 
 
 
 
Hemodynamically unstable (systolic BP < 80mm Hg)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Emergent CT angiography in ER
 
 
 
 
 
 
 
Operating room:
Ready for Endovascular and Open Surgical Repair
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ General anesthesia
Femoral artery cutdown
Aortic balloon occlusion
 
 
 
 
❑ Percutaneous femoral access
Aortic balloon occlusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suitable aortic neck
 
 
 
Unsuitable aortic neck
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endovascular Aneurysm Repair (EVAR)
 
 
 
Aortic occlusion balloon
Laparotomy
❑ Open surgical repair
 
 
 
 

Asymptomatic Abdominal Aortic Aneurysms

[10]
 
 
 
 
 
 
 
 
 
 
Uruptured AAAs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate the dilatation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
< 4.5 cm
 
4.5-5 cm
 
 
 
5-5.5 cm
 
 
 
> 5.5 cm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Follow up
Ultrasonography every 6 months
 
❑ Follow up
Ultrasonography every 3 months
 
Surgery:
Open or Endovascular Aneurysm Repair (EVAR) if:
❑ Female patient
❑ Positive family history
❑ Rapid growth
❑ Positive pet scan
❑ High serum markers (such as MMP-9)
 
 
 
❑ Follow up
Ultrasonography every 3 months
 
Surgery:
Open or Endovascular Aneurysm Repair (EVAR)
 
 
 

Do's

Don'ts

References

  1. 1.0 1.1 Lindeman JH, Matsumura JS (2019). "Pharmacologic Management of Aneurysms". Circ Res. 124 (4): 631–646. doi:10.1161/CIRCRESAHA.118.312439. PMC 6386187. PMID 30763216.
  2. Owens, Douglas K.; Davidson, Karina W.; Krist, Alex H.; Barry, Michael J.; Cabana, Michael; Caughey, Aaron B.; Doubeni, Chyke A.; Epling, John W.; Kubik, Martha; Landefeld, C. Seth; Mangione, Carol M.; Pbert, Lori; Silverstein, Michael; Simon, Melissa A.; Tseng, Chien-Wen; Wong, John B. (2019). "Screening for Abdominal Aortic Aneurysm". JAMA. 322 (22): 2211. doi:10.1001/jama.2019.18928. ISSN 0098-7484.
  3. 3.0 3.1 Canadian Task Force on Preventive Health Care (2017). "Recommendations on screening for abdominal aortic aneurysm in primary care". CMAJ. 189 (36): E1137–E1145. doi:10.1503/cmaj.170118. PMC 5595553. PMID 28893876.
  4. Mussa, Firas F. (2015). "Screening for abdominal aortic aneurysm". Journal of Vascular Surgery. 62 (3): 774–778. doi:10.1016/j.jvs.2015.05.035. ISSN 0741-5214.
  5. Lim, Lionel S.; Haq, Nowreen; Mahmood, Shamail; Hoeksema, Laura (2011). "Atherosclerotic Cardiovascular Disease Screening in Adults". American Journal of Preventive Medicine. 40 (3): 381.e1–381.e10. doi:10.1016/j.amepre.2010.11.021. ISSN 0749-3797.
  6. 6.0 6.1 Moll, F.L.; Powell, J.T.; Fraedrich, G.; Verzini, F.; Haulon, S.; Waltham, M.; van Herwaarden, J.A.; Holt, P.J.E.; van Keulen, J.W.; Rantner, B.; Schlösser, F.J.V.; Setacci, F.; Ricco, J.-B. (2011). "Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery". European Journal of Vascular and Endovascular Surgery. 41: S1–S58. doi:10.1016/j.ejvs.2010.09.011. ISSN 1078-5884.
  7. LeFevre, Michael L. (2014). "Screening for Abdominal Aortic Aneurysm: U.S. Preventive Services Task Force Recommendation Statement". Annals of Internal Medicine. 161 (4): 281. doi:10.7326/M14-1204. ISSN 0003-4819.
  8. Hirsch, Alan T.; Haskal, Ziv J.; Hertzer, Norman R.; Bakal, Curtis W.; Creager, Mark A.; Halperin, Jonathan L.; Hiratzka, Loren F.; Murphy, William R.C.; Olin, Jeffrey W.; Puschett, Jules B.; Rosenfield, Kenneth A.; Sacks, David; Stanley, James C.; Taylor, Lloyd M.; White, Christopher J.; White, John; White, Rodney A. (2006). "ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)". Circulation. 113 (11). doi:10.1161/CIRCULATIONAHA.106.174526. ISSN 0009-7322.
  9. Mehta, Manish; Taggert, John; Darling, R. Clement; Chang, Benjamin B.; Kreienberg, Paul B.; Paty, Philip S.K.; Roddy, Sean P.; Sternbach, Yaron; Ozsvath, Kathleen J.; Shah, Dhiraj M. (2006). "Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: Outcomes of a prospective analysis". Journal of Vascular Surgery. 44 (1): 1–8. doi:10.1016/j.jvs.2006.02.057. ISSN 0741-5214.
  10. Sakalihasan, N; Limet, R; Defawe, OD (2005). "Abdominal aortic aneurysm". The Lancet. 365 (9470): 1577–1589. doi:10.1016/S0140-6736(05)66459-8. ISSN 0140-6736.
  11. Nakayama, Atsuko; Morita, Hiroyuki; Nagayama, Masatoshi; Hoshina, Katsuyuki; Uemura, Yukari; Tomoike, Hitonobu; Komuro, Issei (2018). "Cardiac Rehabilitation Protects Against the Expansion of Abdominal Aortic Aneurysm". Journal of the American Heart Association. 7 (5). doi:10.1161/JAHA.117.007959. ISSN 2047-9980.
  12. Aune D, Schlesinger S, Norat T, Riboli E (2018). "Tobacco smoking and the risk of abdominal aortic aneurysm: a systematic review and meta-analysis of prospective studies". Sci Rep. 8 (1): 14786. doi:10.1038/s41598-018-32100-2. PMC 6170425. PMID 30283044.