An abdominal aortic aneurysm (AAA) is a pathological dilatation of the normal aortic lumen that can be either fusiform or saccular in shape. AAAs affect about 2% of the population and rupture risk increases with diameter. Elective repair has a mortality of 1.5% while emergency repair has a 50% mortality rate. Screening is recommended for men aged 65-75 who smoke and men and women over 50 with a family history. Surgical repair or endovascular repair depends on aneurysm anatomy, with endovascular repair allowing for shorter hospital stays and recovery times. Prompt recognition and treatment of a ruptured AAA is critical to reduce high mortality rates from rupture.

1. Tigran Garabedyan, DO PGY3 ARMC

2. 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

4. AAA present in 2% of population Incidence is increasing 9 th 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%

5. 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!

6. 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

7. 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

8. Vague abdominal pain Blue toe syndrome Palpable mass Popliteal aneurism- 64% have AAA

9. Classic triad Acute onset abdominal and flank pain Shock Palpable abdominal mass Additional Symptoms Death Tachycardia Diaphoresis Back pain Abdominal distention/tenderness

10. 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

11. 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

12. 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

14. 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

21. Recognize AAA potential ABC’s Treat shock Compensated Uncompensated Drive fast

22. Initiate triage Index of suspicion BP management Clinical imaging Treat like major trauma Ultrasound CAT scan Massive resuscitation protocol Immediate operative intervention

23. Recognition, Recognition, Recognition Rapid transport Prompt effective treatment “ Trauma mindset” Physician/facility experience & expertise Outcome measures

24. Uptodate Medscape Tintinalli Google Thank you!