Abdominal Aortic Aneurysms

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  • “Leriche syndrome” - An atherosclerotic occlusive condition involving the abdominal aorta and/or both of the iliac arteries
  • Most AAAs occur in the infrarenal portion of the aorta. The aorta bifurcates into the L and R iliac arteries at approximately the level of the umbilicus and L4, and these AAAs can be palpated through the abdominal wall just above this point.
  • Abdominal Aortic Aneurysms

    1. 1. Abdominal Aortic Aneurysms By Theodore Graphos
    2. 2. PATIENT CASE52 y/o male presenting to MMC for an electiveabdominal aortic aneurysm (AAA) repair.Presentation Labs/Vitals Palpable pulsitile mass in Temp: 36.7 C the epigastric area HR: 62 Intermittent abdominal pain RR: 16 Abdominal CT BP: 117/83  7.9 cm AAA  Large mural thrombus 146 4.2 6 116 completely occluding 106 28.8 0.79 the vessel lumen
    3. 3. PATIENT CASE52 y/o male presenting to MMC for an electiveabdominal aortic aneurysm (AAA) repair.PMH Meds1. AAA (Dx in 2010) Tramadol2. Hypertension Simvastatin3. Hyperlipidemia Amlodipine4. Depression Metoprolol5. Intermittent claudication Zolpidem6. Smoking
    4. 4. PATIENT CASE52 y/o male presenting to MMC for an electiveabdominal aortic aneurysm (AAA) repair.
    5. 5. PATHOPHYSIOLOGYAAAs develop as a result of chronic aortic wallinflammation 4 Arterial injury  Hypertension  Hyperlipidemia  Toxins (nicotine) Inflammation Degradation of elastin AAA growth & rupture
    6. 6. 7EPIDEMIOLOGY >32,000 cases in the U.S. every year 75% of aneurysms ≥4 cm in diameter can be positively liked to a history of smoking♂ Men are at 4-6 times greater risk of developing an AAA Incidence increases with age Affects 2-5% of men >50 yrs; Rare in patients <50 yrs Positive family history of AAA can double the risk
    7. 7. 2,7PRESENTATION Most AAAs are small and are discovered incidentally Insidious development, rarely causing symptomsSymptoms  Pain  Dull, vague pain in the abdomen, back, or flank  Can be acute and severe in ruptured AAAs  Mass  Sensation of a pulsitile mass in the abdomen  Hypotension  Usually manifesting as syncope  Occuring in cases of ruptured AAAs
    8. 8. 2PRESENTATIONAssociated complications Diminished femoral pulses "Blue Toe" Syndrome  D/t microemboli from aortic thrombus Duodenal obstruction leading to vomiting and weight loss Vertebral body erosion leading to severe back pain
    9. 9. PRESENTATIONRisk of rupture AAA Diameter Rupture risk 5is dependent on… (cm) (%/yr) <4 0 Diameter 4-5 0.5-5 Shape 5-6 3-15 (Fusiform < Saccular) 6-7 10-20 7-8 20-40 Growth rate >8 30-50Repair is recommended for… 6 Fusiform AAAs ≥ 5.5 cm in diameter Pts presenting w/ back or abdominal pain
    10. 10. TREATMENT
    11. 11. TREATMENT AAA Diagnosed Small/Stable AAA Large/Unstable AAA Ruptured AAA Surveillance Surgery 6Goal:Slow the rate of AAA growth such that itdoes not reach the threshold for rupturewithin the patient’s lifetime
    12. 12. TREATMENT SURVEILLANCESmoking Cessation Recommended Strong High The single, most important modifiable risk-factor12 Review Human (N>3 million) Smoking was associated with a 3- to 6-fold increased risk of an aortic aneurysmStatins Recommended Weak Low16 Observational AAA patients Statin use was associated with a (N=150) significantly decreased rate of AAA growth (1.16 mm/yr less than non-users).17 Observational AAA patients Statin use was associated with significantly (N=130) less AAA growth at an average follow-up of 4 years (p<0.001)
    13. 13. TREATMENT SURVEILLANCEACE Inhibitors Insufficient Ev idence Weak Low 10 Observational AAA patients Use of ACE inhibitors was less frequent in (N=15,326) patients who presented to the hospital with a ruptured AAA.Doxycycline & Insufficient Ev idence Weak LowRoxithromycin 1 Experimental AAA patients Doxycycline 6-mo course significantly (N=36) reduced mean MMP-9 levels13 RCT AAA patients Aneurysm expansion was significantly (N=32) slower in the doxycycline group at >6 mo.18 RCT AAA patients Aneurysm expansion was significantly (N=92) slower in the roxithromycin group over the first year
    14. 14. TREATMENT SURVEILLANCEBeta-Blockers NOT Recommended Weak Low11 Observational AAA patients Patients receiving a beta-blocker had a (N=27) significantly slower rate of AAA growth. 9 Observational AAA patients Patients receiving a beta-blocker had a (N=121) significantly slower (p=0.02) rate of AAA growth.20 RCT AAA patients Patients receiving propranolol had a non- (N=548) statistically-significant difference in AAA growth rate (p=0.11) and mortality (p=0.36)19 RCT AAA patients Patients receiving propranolol had a non- (N=477) statistically-significant difference in AAA growth rate (p=0.48)
    15. 15. 6 TREATMENT SURGERYPre-Operative  Antibiotic prophylaxis  1st or 2nd generation cephalosporin or vancomycin  Within 30 minutes of incision  Continued for no more than 24 hours post-opPost-Operative  Analgesia  Epidural or PCA after an open AAA repair  DVT prophylaxis  SCDs and early ambulation for all patients  Anticoagulant therapy for patients at high risk of developing a DVT
    16. 16. TREATMENT SURGERY
    17. 17. 8 TREATMENT SURGERY Beta-blockers, statins, alpha-2 agonists, and calcium channel blockers to reduce cardiac risk Pain management VTE prophylaxis Glucose control Post-operative arrhythmias  Beta-blockers are the preferred agent for patients with a post-operative supraventricular arrhythmia  Cardioversion is only recommended in hemodynamically unstable patients
    18. 18. TREATMENT SURGERY No guideline-supported recommendations for post-operative hyper- or hypotension after AAA repair.  Typically, a MAP that differs from pre-operative readings by >20% should be treated. 15
    19. 19. PATIENT CASE 4/17 OR for AAA repair. Aortic bifemoral bypass graft placed. BP managed with nitroprusside drip. 4/19 Pt extubated and off sedation and nitroprusside. 4/20 Pt desatted and was reintubated. W/u revealed CAP and L-sided PTX. EKG revealed pt was in a-fib w/ RVR. Abx for CAP and metoprolol for a-fib. 4/23 Pt extubated and recovering from CAP. 4/25 Pt back to NSR. Out to floor. 4/27 Discharged to home.
    20. 20. References1. Baxter BT, Pearce WH, Waltke EA, et al. Prolonged administration of doxycycline in patients with small asymptomatic abdominal aortic aneurysms: report of a prospective (Phase II) multicenter study. Journal of vascular surgery  official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. : 2002;36(1):1-12. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12096249. Accessed May 1, 2012.2. Bessen HA. Abdominal Aortic Aneurysm. In: Marx JA, ed. Rosen’s emergency medicine: Concepts and Clinical Practice. 7th Ed. Elsevier Inc. 2010:1093-1102. Available at: http://dx.doi.org/10.1016/B978-0-323-05472-0.00084-0.3. Brady AR, Thompson SG, Fowkes FGR, Greenhalgh RM, Powell JT. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. Circulation. 2004;110(1):16-21. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15210603. Accessed April 5, 2012.4. Braverman AC, Thompson RW, Sanchez LA. Diseases of the Aorta. In: Bonow RO, Mann DL, Zipes DP, Libby P, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 9th Ed. Elsevier Inc. 2011:1309-e83. Available at: http://dx.doi.org/10.1016/B978-1-4377-0398-6.00060-3.5. Brewster DC, Cronenwett JL, Hallett JW, et al. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. Journal of vascular surgery  official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular : Surgery, North American Chapter. 2003;37(5):1106-17. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12756363. Accessed March 16, 2012.6. Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2009;50(4 Suppl):S2-49. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19786250. Accessed March 6, 2012.7. Fillinger MF. Abdominal Aortic Aneurysms: Evaluation and Decision Making. In: Cronenwett JL, Johnston KW, eds. Rutheford’s Vascular Surgery. 7th Ed. Elsevier Inc. 2010:1928-1948.8. Fleisher L a, Beckman J a, Brown K a, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007;116(17):e418-99. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17901357. Accessed March 2, 2012.9. Gadowski GR, Pilcher DB, Ricci MA. Abdominal aortic aneurysm expansion rate: effect of size and beta-adrenergic blockade. Journal of vascular surgery  official publication, the Society : for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 1994;19(4):727-31. Available at: http://www.ncbi.nlm.nih.gov/pubmed/7909340. Accessed May 1, 2012.10. Hackam DG, Thiruchelvam D, Redelmeier DA. Angiotensin-converting enzyme inhibitors and aortic rupture: a population-based case-control study. Lancet. 2006;368(9536):659-65. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16920471. Accessed May 1, 2012.11. Leach SD, Toole AL, Stern H, DeNatale RW, Tilson MD. Effect of beta-adrenergic blockade on the growth rate of abdominal aortic aneurysms. Archives of surgery (Chicago, Ill.  1960). : 1988;123(5):606-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/2895995. Accessed May 1, 2012.12. Lederle FA, Nelson DB, Joseph AM. Smokers’ relative risk for aortic aneurysm compared with other smoking-related diseases: a systematic review. Journal of vascular surgery  official : publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2003;38(2):329-34. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12891116. Accessed May 1, 2012.13. Mosorin M, Juvonen J, Biancari F, et al. Use of doxycycline to decrease the growth rate of abdominal aortic aneurysms: a randomized, double-blind, placebo-controlled pilot study. Journal of vascular surgery  official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2001;34(4):606-10. Available at: : http://www.ncbi.nlm.nih.gov/pubmed/11668312. Accessed May 1, 2012.14. Papia G, Cina CS. Postoperative Management. In: Cronenwett JL, Johnston KW, eds. Rutheford’s Vascular Surgery. 7th Ed. Elsevier Inc. 2010:501-516.15. Papia G, Klein D, Lindsay TF. Intensive care of the patient following open abdominal aortic surgery. 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