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Overview
 

 
Snapshot
  • AAAA 61-year-old male with a history of CAD and HTN is found to have a pulsatile abdominal mass on palpation. A bruit is heard on ausculation.
Introduction
  • Characterized by ballooning (aneurysmal) dilatation of the aorta
  • Occurs most commonly secondary to atherosclerosis
    • most are abdominal in origin
      • 90% occur below the renal arteries
    • rarely present at or around the aortic arch
  • Risk factors include
    • HTN
    • hypercholesterolemia
    • atherosclerosis
    • family history
    • tobacco
    • male gender
    • increasing age
    • Marfan's syndrome
Presentation
  • Symptoms
    • usually asymptomatic 
      • discovered incidentally on exam or imaging study
    • can present with
      • pulsatile sensation
      • back pain
      • vague epigastric pain
    • ruptured aneurysms present with 
      • hypotension
      • severe, tearing abdominal pain radiating to the back
  • Physical exam
    • pulsatile mass in the abdomin
    • abdominal bruits
    • evidence of lower extremity arterial insufficiency
Imaging
  • Ultrasound 
    • all men age 65+ who have ever smoked should be screened with an ultrasound
    • is diagnostic gold standard
      • < 5 cm => monitor with repeat ultrasounds
      • > 5 cm => surgical repair and further management
    • used to follow AAA over time
  • AXR/KUB
    • may show vascular calcification
  • CT
    • best modality to determine anatomy and size
  • Aortogram
    • for definitive diagnosis
Differential
  • Pancreatitis, pseudocyst, appendicitis, gallbladder disease, aortic dissection
Treatment
  • Nonoperative
    • clinical observation
      • indications
        •  asymptomatic and < 5 cm in size
        • < 6 cm in poor surgical candidate
  • Operative
    • surgical repair  
      • indications
        • large lesions
          • > 5.5 cm in the abdomen 
          • > 6 cm in the thoracic cavity
        • smaller lesions that are rapidly enlarging on follow-up
    • emergent surgery 
      • indications
        • symptomatic lesions
        • ruptured aneurysms
Complications
  • Myocardial infarct
    • is the most common cause of death after elective surgical repair
  • Thrombosis and post-operative emboli
    • can lead to
      • renal failure
      • GI hemorrhage from colonic ischemia 
  • Aortoduodenal fistula
    • can occur s/p surgery and graft placement
    • presents with GI bleed
  • Other complications
    • endograft infection, ischemia of internal organs (including kidney, intestines, and pelvic organs)
    • contrast-induced nephropathy or allergic reaction
    • aortocaval fistula (though rare)
    • gross hematuria 2/2 congestion of weak bladder veins leading to rupture
Prognosis & Prevention
  • Prognosis
    • ranges depending on severity of lesion and timing of diagnosis
      • good to excellent in smaller lesions and when identified early
      • poor if aneurysm leads to dissection and/or rupture
  • Prevention
    • possible if identified early via thorough physical exam and regular primary care visits
    • screening with ultrasound indicated in men ages 65-75 who have ever smoked 
 

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