Updated: 1/16/2021

Abdominal Aortic Aneurysm

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Snapshot
  • A 67-year-old man presents to his primary care physician due to vague epigastric discomfort. He denies it being associated with meals and reports that this pain occurred insidiously.  Medical history is significant for hypertension. He has been smoking 1-pack of cigarettes per day for the past 30 years. On physical exam, he has a pulsatile abdominal mass that is tender to palpation. An abdominal ultrasound is performed, which demonstrates a 6 cm abdominal aortic aneurysm. He is scheduled for an elective abdominal repair surgery for the following day.
Introduction
  • Clinical definition
    • a segmental and full thickness dilation of the abdominal aorta 
  • Epidemiology
    • risk factors
      • age
      • male gender
      • cigarette smoking (greatest risk factor) 
      • family history
      • Caucasian race
      • atherosclerosis
  • Pathogenesis
    • pathoanatomy
      • the abdominal aorta is a retroperitoneal structure that
        • begins in the hiatus of the diaphragm
        • bifurcates into the right and left iliac common arteries
          • these arteries can also become aneurysmal
      • an aneurysm typically develops below the renal arteries and above the common iliac arteries
    • pathophysiology
      • elastin fibers become disrupted and collagen becomes degraded, resulting in a loss of elasticity in the aortic wall
  • Prognosis
    • risk of rupture increases with size
Presentation
  • Symptoms/physical exam
    • asymptomatic (the majority of cases)
      • an enlarged abdominal mass and an abdominal bruit may be found
    • in symptomatic but not ruptured cases
      • abdominal, back, or flank pain 
    • in symptomatic, ruptured cases  
      • severe pain, hypotension, and a pulsatile mass 
Imaging
  • Abdominal CT (contrast-enhanced) 
    • indication
      • in symptomatic patients who are hemodynamically stable 
  • Abdominal ultrasound
    • indication
      • USPSTF recommends that screen be performed 1 time in men who
        • are 65-75 years of age
        • smoked at any time
      • serial imaging in patients with an abdominal aortic aneurysm (AAA) < 5 cm
Treatment
  • Conservative
    • smoking cessation
      • indication
        • for all patients
      • comments
        • proven to decrease the rate of aneurysm expansion 
  • Operative
    • AAA repair  
      • indication 
        • ruptured AAA (surgical emergency)  
        • symptomatic and unruptured cases
          • abdominal aortic aneurysm ≥ 5.5 cm
          • AAA smaller than 5.5cm, but rapidly expanding (>0.5cm over 6 months)
Complications
  • Rupture

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Questions (11)
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(M3.CV.15.23) A 73-year-old woman with a history of hypertension, diabetes, and coronary artery disease presents to the emergency department with severe back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. Her temperature is 98.1°F (36.7°C), blood pressure is 80/50 mm Hg, pulse is 130/min, respiratory rate is 17/min, and oxygen saturation is 98% on room air. A bedside ultrasound of the abdomen is performed as seen in Figure A. What is the best next step management for this patient's current presentation?

QID: 103046
FIGURES:
1

CT scan

18%

(2/11)

2

Discharge and serial outpatient ultrasounds

0%

(0/11)

3

Endovascular surgical repair

73%

(8/11)

4

Tranexamic acid

0%

(0/11)

5

Volume resuscitation and observation

0%

(0/11)

M 11 E

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(M3.CV.14.19) A 79-year-old man presents to the emergency department with abdominal pain. The patient describes the pain as severe, tearing, and radiating to the back. His history is significant for hypertension, hyperlipidemia, intermittent claudication, and a 60 pack-year history of smoking. He also has a previously diagnosed stable abdominal aortic aneurysm followed by ultrasound screening. On exam, the patient's temperature is 98°F (36.7°C), pulse is 183/min, blood pressure is 84/46 mmHg, respirations are 24/min, and oxygen saturation is 99% on room air. The patient is pale and diaphoretic, and becomes confused and obtunded as you examine him. Which of the following is most appropriate in the evaluation and treatment of this patient?

QID: 103042
1

Abdominal ultrasound

0%

(0/2)

2

Abdominal CT with contrast

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(0/2)

3

Abdominal CT without contrast

0%

(0/2)

4

Abdominal MRI

0%

(0/2)

5

Surgery

100%

(2/2)

M 11 E

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(M3.CV.12.2) A 68-year-old male with past history of hypertension, hyperlipidemia, and a 30 pack/year smoking history presents to his primary care physician for his annual physical. Because of his age and past smoking history, he is sent for screening abdominal ultrasound. He is found to have a 4 cm infrarenal abdominal aortic aneurysm. Surgical repair of his aneurysm is indicated if which of the following are present?

QID: 103654
1

Abdominal, back, or groin pain

83%

(5/6)

2

Smoking history

17%

(1/6)

3

Diameter >3 cm

0%

(0/6)

4

Growth of < 0.5 cm in one year

0%

(0/6)

5

Marfan's syndrome

0%

(0/6)

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Evidence (9)
EXPERT COMMENTS (11)
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