aortic abdominal aneurism
TRANSCRIPT
Tigran Garabedyan, DOPGY3ARMC
Definition: pathological dilatation of the normal aortic lumen involving one or several segments
Fusiform -circumferential (common), Saccular- outpouching of a
segment Pseudoaneurysm: well-defined
collection of blood and connective tissue outside the vessel wall
AAA present in 2% of population Incidence is increasing 9th leading cause of death in the USA -
15,000 annually After rupture only 25% reach ED alive,
10% make it to OR alive Natural history is to enlarge and rupture Elective operative mortality-1.5% Emergent operative mortality-50% Free rupture mortality- > 90%
AAA diameter (cm) Rupture risk (%/y) <4 0 4-5 0.5-5 5-6 3-15 6-7 10-20 7-8 20-40 >8 30-50
Risk of Rupture is higher than risks associated with repair (5-5.5)
Size really does matter!
Age (M>55 y/o; F>70 y/o) Male Atherosclerosis – especially PVD Gene (Marfan, Ehlers-Danlos syndrome) Aneurisms of the femoral or popliteal Smoking- 7 fold risk, 90% OF AAA are
smokers Family history- 4 fold risk
Pain: most common, at hypogastrium or back, not affected by movement
75 % asymptomatic Rupture triad: abdominal or back pain;
palpable/ pulsatile abdominal mass; hypotension (<1/3 cases)
Bruit (+/-) Abdomianl echo, CT, MRA, aortography
Vague abdominal pain Blue toe syndrome Palpable mass Popliteal aneurism- 64% have AAA
Classic triad Acute onset abdominal and flank pain Shock Palpable abdominal mass
Additional Symptoms Death Tachycardia Diaphoresis Back pain Abdominal distention/tenderness
The USPSTF recommends: Men 65-75 year old who have ever
smoked Men and women older than 50 with a
family history Against screening women Women 60-85 year old with cardiac risk
factors
Surgical indication: rupture; size >5.5cm; expanding rapidly (>1.5 cm/year)
Coronary angiography Medication control: Hyperlipidemia,
hypertension, cigarette smoking cessation
CT follow up every 3—6 months
Surgical repair vs Endovascular repair Depends on “anatomic features of AAA
Endovascular Aneurism “neck”, relationship to renal arteries Iliac arterial size Hospital stay 2-3 days Small incision in groin Back to normal activity in about a week Yearly CT angiograms post-op
Surgical In 2010, non-endovascular candidates Younger patients Patient preference Hospital stay 5-7 days, 1-2 in ICU High mortality Big incision No yearly follow-ups post -op
Recognize AAA potential ABC’s Treat shock
Compensated Uncompensated
Drive fast
Initiate triage Index of suspicion BP management Clinical imaging
Treat like major trauma Ultrasound CAT scan
Massive resuscitation protocol Immediate operative intervention
Recognition, Recognition, Recognition Rapid transport Prompt effective treatment “Trauma mindset” Physician/facility experience & expertise Outcome measures
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Thank you!