Abdominal aortic aneurysm

Background

Aortic sebments.
Branches of the aorta.
CT reconstruction image of an abdominal aortic aneurysm (white arrows).
  • Different types
    • Fusiform (~92%)- Bulging or ballooning of all sides of the aorta
    • Saccular (~5%)- Bulging or ballooning of only one side of the aorta
    • Mycotic (less than 3%)- Caused by an infection of the vessel wall
      • More common in Asian countries, can be as much as 13%
      • May be bacterial, viral, or fungal
      • May be a complication of infectious endocarditis
      • Increased risk of rupture
  • Infrarenal diameter >3cm or >50% increase in size of diameter
    • 85% of cases are infrarenal [1]
    • Mean growth rate is about 0.2-0.3 cm/yr
  • Rupture Risk
    • <4cm: low risk for rupture
    • 4-5cm: 5 year risk 3-12%
    • >5cm: 25-41%
    • Rupture possible at any size, most commonly >5cm
    • Mortality with rupture: 85-90% [1]

Risk Factors

  • Gender (male to female ratio 4:1)
  • Smoking
    • Risk factor most strongly associated with AAA
    • Also promotes the rate of aneurysm growth
    • Direct relationship between risk and number of smoking years
  • Age (prevalence is negligible in age <50yrs)
  • Family history
  • Hypertension
  • Hyperlipidemia
  • Fluoroquinolone use [2]

Clinical Features

  • Classic triad (only 50% of cases) is pain + hypotension + pulsatile mass
    • Pain often described as sudden, severe, radiating to back, ripping quality
  • Syncope (10%)
  • Signs of Retroperitoneal hemorrhage
  • Massive GI bleed from aortoenteric fistula
  • Pain + AAA = rupture until proven otherwise
  • Acute abdomen + hypotension = possible rupture
  • Gross hematuria can be caused by an aortocaval fistula (very rare)
  • Unruptured aneurysms are frequently asymptomatic

Differential Diagnosis

Diffuse Abdominal pain

Lower Back Pain

Evaluation

AAA
Ultrasound of AAA with Thrombus (click to view).[3]
Abdominal aortic aneurysm seen on CT with a small area of remaining blood flow (white).
Sagital reconstruction of aortic aneurysm
  • Labs
    • Coagulation studies
    • Creatinine
    • Urinalysis
    • CBC
    • Type and cross-match blood


  • Imaging
    • Ultrasound
      • ~99% sensitive/98% specific for increased diameter[4]
      • Cannot reliably visualize rupture (only 4% sensitive)[5]
    • CT
      • ~100% sensitive for increased diameter and rupture
      • IV contrast is preferred but not essential

Management

Rupture

Ruptured AAA with an open arrow marking the aneurysm and the closed arrow marking the free blood in the abdomen.
  • Do not waste time in ED trying to "stabilize" patient
  • Immediate surgery consultation/ go to OR
  • Crossmatch 6 units of pRBC
  • Pain control (avoid hypotension)
  • Antihypertensives (use with caution, goal SBP 110-120 mmHg or MAP 70-80)[6]
    • Labetalol: 20mg IV, then 40-80mg IV q10 min (max 300mg)
    • Esmolol: Bolus 500 mcg/kg, then 50-200 mcg/kg/min
    • Nitroprusside: 0.3 - 0.5 mcg/kg/min, titrate to max 10 mcg/kg/min
  • Controversial
    • Too little (ischemia), too much (increased bleeding)
      • Consider allowing for permissive hypotension (SBP 70-90) in conscious patient[7]
    • Pressors
      • Norepinephrine 0.05mcg/kg/min IV; titrate by 0.02mcg/kg/min q5min
      • Phenylephrine 100-180mcg/min; titrate by 25mcg/min q10min
      • Dopamine 5mcg/kg/min; titrate by 5mcg/kg/min q10min

Asymptomatic

  • Aneurysm > 5 cm: Prompt (within days) vascular surgery outpatient follow-up appt
    • Endovascular (75%) vs open repair
  • Aneurysm 3-5 cm: Can likely follow up with PCP/surgeon on non-urgent basis
  • Screening frequency:
    • 3-4 cm diameter: 12 months
    • 4-5 cm diameter: 6 months
    • 5-6 cm diameter: 1 month
  • Elective Surgery indicated if:
    • AAA > 5.5 cm in men [1]
    • AAA > 5 cm in women [1]
    • increase in size > 1 cm/year
    • increase in size > 5 mm/6 months

Complications

Disposition

  • Admit to OR for ruptured or symptomatic AAA
  • May discharge asymptomatic cases with close vascular surgery follow up
    • Instruct to return immediately if symptoms manifest (abdominal/back pain, syncope, dizziness, extremity pain)

External Links

References

  1. ↑ 1.0 1.1 1.2 1.3 Kent, K. Abdominal Aortic Aneurysms. The New England Journal of Medicine. 2014; 371:2101-8. DOI: 10.1056/NEJMcp1401430
  2. ↑ P. Wendling for Medscape. FDA Warns of Aortic Aneurysm Risk with Fluoroquinolones. https://www.medscape.com/viewarticle/906867. Accessed 12/26/2018.
  3. ↑ http://www.thepocusatlas.com/aorta-1/
  4. ↑ Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013;20(2):128-138. doi:10.1111/acem.12080
  5. ↑ Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013;20(2):128-138. doi:10.1111/acem.12080
  6. ↑ Reed, K. Aortic Emergencies, EB Medicine. 2006.
  7. ↑ Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2-77.e2. doi:10.1016/j.jvs.2017.10.044
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