Aortic abdominal aneurism

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  • No rupture
  • Infra renal AAA
  • Aortic abdominal aneurism

    1. 1. Tigran Garabedyan, DO PGY3 ARMC
    2. 2. <ul><li>Definition: pathological dilatation of the normal aortic lumen involving one or several segments </li></ul><ul><li>Fusiform -circumferential (common) , </li></ul><ul><li>Saccular- outpouching of a segment </li></ul><ul><li>Pseudoaneurysm: well-defined collection of blood and connective tissue outside the vessel wall </li></ul>
    3. 4. <ul><li>AAA present in 2% of population </li></ul><ul><li>Incidence is increasing </li></ul><ul><li>9 th leading cause of death in the USA -15,000 annually </li></ul><ul><li>After rupture only 25% reach ED alive, 10% make it to OR alive </li></ul><ul><li>Natural history is to enlarge and rupture </li></ul><ul><li>Elective operative mortality-1.5% </li></ul><ul><li>Emergent operative mortality-50% </li></ul><ul><li>Free rupture mortality- > 90% </li></ul>
    4. 5. <ul><li>AAA diameter (cm) Rupture risk (%/y) </li></ul><ul><ul><li><4 0 </li></ul></ul><ul><ul><li>4-5 0.5-5 </li></ul></ul><ul><ul><li>5-6 3-15 </li></ul></ul><ul><ul><li>6-7 10-20 </li></ul></ul><ul><ul><li>7-8 20-40 </li></ul></ul><ul><ul><li>>8 30-50 </li></ul></ul><ul><ul><li>Risk of Rupture is higher than risks associated with repair (5-5.5) </li></ul></ul><ul><ul><li>Size really does matter! </li></ul></ul>
    5. 6. <ul><li>Age (M>55 y/o; F>70 y/o) </li></ul><ul><li>Male </li></ul><ul><li>Atherosclerosis – especially PVD </li></ul><ul><li>Gene (Marfan, Ehlers-Danlos syndrome) </li></ul><ul><li>Aneurisms of the femoral or popliteal </li></ul><ul><li>Smoking- 7 fold risk, 90% OF AAA are smokers </li></ul><ul><li>Family history- 4 fold risk </li></ul>
    6. 7. <ul><li>Pain: most common, at hypogastrium or back, not affected by movement </li></ul><ul><li>75 % asymptomatic </li></ul><ul><li>Rupture triad : abdominal or back pain; palpable/ pulsatile abdominal mass; hypotension (<1/3 cases) </li></ul><ul><li>Bruit (+/-) </li></ul><ul><li>Abdomianl echo, CT, MRA, aortography </li></ul>
    7. 8. <ul><li>Vague abdominal pain </li></ul><ul><li>Blue toe syndrome </li></ul><ul><li>Palpable mass </li></ul><ul><li>Popliteal aneurism- 64% have AAA </li></ul>
    8. 9. <ul><li>Classic triad </li></ul><ul><ul><li>Acute onset abdominal and flank pain </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>Palpable abdominal mass </li></ul></ul><ul><li>Additional Symptoms </li></ul><ul><ul><li>Death </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>Back pain </li></ul></ul><ul><ul><li>Abdominal distention/tenderness </li></ul></ul>
    9. 10. <ul><li>The USPSTF recommends: </li></ul><ul><ul><li>Men 65-75 year old who have ever smoked </li></ul></ul><ul><ul><li>Men and women older than 50 with a family history </li></ul></ul><ul><ul><li>Against screening women </li></ul></ul><ul><ul><li>Women 60-85 year old with cardiac risk factors </li></ul></ul>
    10. 11. <ul><li>Surgical indication: rupture; size >5.5cm; expanding rapidly (>1.5 cm/year) </li></ul><ul><li>Coronary angiography </li></ul><ul><li>Medication control: Hyperlipidemia, hypertension, cigarette smoking cessation </li></ul><ul><li>CT follow up every 3—6 months </li></ul>
    11. 12. <ul><li>Surgical repair vs Endovascular repair </li></ul><ul><ul><li>Depends on “anatomic features of AAA </li></ul></ul><ul><li>Endovascular </li></ul><ul><ul><li>Aneurism “neck”, relationship to renal arteries </li></ul></ul><ul><ul><li>Iliac arterial size </li></ul></ul><ul><ul><li>Hospital stay 2-3 days </li></ul></ul><ul><ul><li>Small incision in groin </li></ul></ul><ul><ul><li>Back to normal activity in about a week </li></ul></ul><ul><ul><li>Yearly CT angiograms post-op </li></ul></ul>
    12. 14. <ul><li>Surgical </li></ul><ul><ul><li>In 2010, non-endovascular candidates </li></ul></ul><ul><ul><li>Younger patients </li></ul></ul><ul><ul><li>Patient preference </li></ul></ul><ul><ul><li>Hospital stay 5-7 days, 1-2 in ICU </li></ul></ul><ul><ul><li>High mortality </li></ul></ul><ul><ul><li>Big incision </li></ul></ul><ul><ul><li>No yearly follow-ups post -op </li></ul></ul>
    13. 21. <ul><li>Recognize AAA potential </li></ul><ul><li>ABC’s </li></ul><ul><li>Treat shock </li></ul><ul><ul><li>Compensated </li></ul></ul><ul><ul><li>Uncompensated </li></ul></ul><ul><li>Drive fast </li></ul>
    14. 22. <ul><li>Initiate triage </li></ul><ul><li>Index of suspicion </li></ul><ul><li>BP management </li></ul><ul><li>Clinical imaging </li></ul><ul><ul><li>Treat like major trauma </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>CAT scan </li></ul></ul><ul><li>Massive resuscitation protocol </li></ul><ul><li>Immediate operative intervention </li></ul>
    15. 23. <ul><li>Recognition, Recognition, Recognition </li></ul><ul><li>Rapid transport </li></ul><ul><li>Prompt effective treatment </li></ul><ul><li>“ Trauma mindset” </li></ul><ul><li>Physician/facility experience & expertise </li></ul><ul><li>Outcome measures </li></ul>
    16. 24. <ul><li>Uptodate </li></ul><ul><li>Medscape </li></ul><ul><li>Tintinalli </li></ul><ul><li>Google </li></ul><ul><li>Thank you! </li></ul>

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