Abdominal Aortic Aneurysms

Eastern Vascular Society

INFRARENAL ASYMPTOMATIC AAA

GOALS:

• Identify presence of asymptomatic aneurysm and quantify their size so that appropriate management (i.e. operation vs. observation ) can be undertaken prior to the development of symptoms.
• Identify aneurysm as a source of symptoms (e.g. hypotension, pain, peripheral ischemia or embolization).

DIFFERENTIAL DIAGNOSIS -
Abdominal aortic aneurysms (AAA) are usually discovered serendipitously during a work-up for other, likely unrelated, intraabdominal complaints. AAA are also found serendipitously at screening abdominal examinations.

PERTINENT HISTORY -
Is the aneurysm symptomatic?
Is the patient female?
Back pain?
Abdominal Pain?
Is the complaint new, acute, or chronic?
Does the pain radiate?
Has the patient any symptoms consistent with hypotension or hypovolemia?
Does the patient have a history of hypertension?
Does the patient claudicate?
Does the patient have any history of cardiopulmonary disease; specifically, angina, dyspnea, myocardial infarction, or stroke?

TREATMENT:

1. Reduction limb size

• Elevation at night 6" blocks
• Elastic fitted hose 30 mmHg minimum (40-50 mmHg needed for lymphedema).
• Intermittent pneumatic compression when A and B fail.

2. Skin Care

• Use water based lotion for moisturizing.
• Aggressive treatment of any infection in leg, foot or toes.

3. For causalgia only - sympathetic block.

• Is there any history of other cardiovascular risk factors?
• Smoking?
• Chronic obstructive pulmonary disease?

PHYSICAL FINDINGS -
Is there hypertension?
Evaluate cardiopulmonary system for presence of COPD or cardiac risk factors such as arrhythmias or murmurs.
What is the clinica estimation of aneurysm size?
Is the aneurysm tender?
What is the status of femoral popliteal and pedal pulses?
Is there evidence of aneurysm in any of these positions?

INITIAL LABORATORY INVESTIGATIONS -
Chest x-ray PA and lateral - rule out thoracic aortic involvement; evaluate for evidence of cardiopulmonary disease.
Electrocardiogram - to rule out evidence of arrhythmia or ischemic cardiac disease.
Abdominal ultrasound - to confirm diagnosis and measure aneurysm size.
BUN and creatinine - to measure renal function.

 

MANAGEMENT ALGORITHM - ASYMPTOMATIC AAA

Ultrasonography to Confirm AAA Size
< 4cm
Repeat ultrasound in 2-3 years
4 - 5 cm
Refer to vascular surgeon for evaluation and follow-up recommendations
> 5 cm
Cardiac risk factor evaluation (history, physical exam, EKG)
If positive, Detailed cardiac evaluation (persantine thallium, exercise stress test, coronary catherterization) If negative, Refer to vascular surgeon

RUPTURED INFRARENAL AAA

GOAL: RAPID IDENTIFICATION OF CONDITION AND TRANSFER TO O.R.

DIFFERENTIAL DIAGNOSIS -
Myocardial infarction, lumbar spine pathology, nephro-urolithiasis

PERTINENT HISTORY -
Is there a known presence of infrarenal abdominal aortic aneurysm?
Is there previous history of back disease or renal stone disease?
Does the patient have cardiac risk factors?
Is the patient?s pain acute or chronic?
Have bowel or urinary habits been affected?
Has the patient lost consciousness, had any chest pain, any symptoms suggestive of hypovolemia?
Is the pain colicky?

PHYSICAL FINDINGS -
Is there hypotension; is there postural hypotension?
Is there a pulsatile abdominal mass?
Is there flank discoloration?

INITIAL LABORATORY INVESTIGATIONS -
Ultrasound - to confirm presence or absence of aneurysm, if there is no pulsatile abdominal mass.
Hemoglobin - to check for blood loss (type and cross should be sent immediately with this sample).
Electrocardiogram - to rule out myocardial infarction or arrhythmia