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Abdominal aortic aneurysm - Wikipedia, the free encyclopedia

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Abdominal aortic aneurysm


From Wikipedia, the free encyclopedia

Abdominal aortic aneurysm

Abdominal aortic aneurysm

(AAA),[1] also known as a triple-a,


is a localized enlargement of the
abdominal aorta such that the
diameter is greater than 3 cm or more
than 50% larger than normal.[2] They
usually cause no symptoms except
when ruptured.[2] Occasionally there
may be abdominal, back or leg
pain.[3] Large aneurysms can
sometimes be felt by pushing on the
abdomen.[3] Rupture may result in
pain in the abdomen or back, low
blood pressure or a brief loss of
consciousness.[2][4]

CT reconstruction image of an abdominal aortic aneurysm (white arrows)


Classification and external resources

AAAs occur most commonly in those


over 50 years old, in men, and among

ICD-10

those with a family history.[2]


Additional risk factors include
smoking, high blood pressure, and
other heart or blood vessel

I71.3
(http://apps.who.int/classifications/icd10/browse/2015/en#/I71.3),
I71.4
(http://apps.who.int/classifications/icd10/browse/2015/en#/I71.4)

ICD-9

441.3 (http://www.icd9data.com/getICD9Code.ashx?
icd9=441.3), 441.4
(http://www.icd9data.com/getICD9Code.ashx?icd9=441.4)

OMIM

100070 (http://omim.org/entry/100070)

diseases.[5]

Genetic conditions with


an increased risk include Marfan
syndrome and Ehlers-Danlos
syndrome. AAAs are the most
common form of aortic aneurysm.[6]
Approximately 85 percent occur
below the kidneys with the rest either
at the level of or above the
kidneys.[2]

In the United States


screening males with ultrasound who
are between 65 and 75 year old and
have a history of smoking is
recommended.[7] In the United
Kingdom screening all men over 65

DiseasesDB 792 (http://www.diseasesdatabase.com/ddb792.htm)


MedlinePlus 000162
(http://www.nlm.nih.gov/medlineplus/ency/article/000162.htm)
eMedicine

med/3443 (http://www.emedicine.com/med/topic3443.htm)
emerg/27 (http://www.emedicine.com/emerg/topic27.htm#)
radio/1 (http://www.emedicine.com/radio/topic1.htm#)

MeSH

D017544 (https://www.nlm.nih.gov/cgi/mesh/2015/MB_cgi?
field=uid&term=D017544)

is recommended.[2] Australia has no guideline on screening.[8] Once an aneurysm is found, further ultrasounds
are typically done on a regular basis.[3]
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Not smoking is the single best way to prevent the disease. Other methods of prevention include treating high
blood pressure, treating high blood cholesterol and not being overweight. Surgery is usually recommended
when an AAA's diameter grows to >5.5 cm in males and >5.0 cm in females.[2] Other reasons for repair include
the presence of symptoms and a rapid increase in size.[3] Repair may be either by open surgery or endovascular
aneurysm repair (EVAR).[2] As compared to open surgery, EVAR has a lower risk of death in the short term and
a shorter hospital stay but may not always be an option.[2][9][10] There does not appear to be a difference in
longer term outcomes between the two.[11] With EVAR there is a higher need for repeat procedures.[12]
AAAs affect between 2% and 8% of males over the age of 65. Rates among women are four times lower. In
those with an aneurysm less than 5.5 cm the risk of rupture in the next year is less than 1%. Among those with
an aneurysm between 5.5 and 7 cm the risk is about 10% while for those with an aneurysm greater than 7 cm
the risk is about 33%. Mortality if ruptured is 85% to 90%.[2] During 2013, aortic aneurysms resulted in
152,000 deaths up from 100,000 in 1990.[13] In the United States AAAs resulted in between 10,000 and 18,000
deaths in 2009.[6]

Contents
1 Signs and symptoms
1.1 Aortic rupture
2 Causes
3 Pathophysiology
4 Diagnosis
4.1 Classification
5 Prevention
6 Screening
7 Management
7.1 Conservative
7.2 Medication
7.3 Surgery
7.4 Rupture
8 Prognosis
9 Epidemiology
10 History
11 Society and culture
12 Research
12.1 Risk assessment
12.2 Experimental models
12.3 Prevention and treatment
13 References
14 External links

Signs and symptoms


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The vast majority of aneurysms are asymptomatic. However, as


abdominal aortic aneurysms expand, they may become painful and lead
to pulsating sensations in the abdomen or pain in the chest, lower back,
or scrotum.[14] The risk of rupture is high in a symptomatic aneurysm,
which is therefore considered an indication for surgery. The
complications include rupture, peripheral embolization, acute aortic
occlusion, and aortocaval (between the aorta and inferior vena cava) or
aortoduodenal (between the aorta and the duodenum) fistulae. On
physical examination, a palpable abdominal mass can be noted. Bruits
can be present in case of renal or visceral arterial stenosis.[15]

Aortic rupture
The signs and symptoms of a ruptured AAA may includes severe pain in
the lower back, flank, abdomen or groin. A mass that pulses with the
heart beat may also be felt.[4] The bleeding can leads to a hypovolemic
shock with low blood pressure and a fast heart rate. This may lead to

Drawing of an abdominal aortic


aneurysm.

brief passing out.[4]


The mortality of AAA rupture is up to 90%. 6575% of patients die before they arrive at hospital and up to 90%
die before they reach the operating room.[16] The bleeding can be retroperitoneal or into the abdominal cavity.
Rupture can also create a connection between the aorta and intestine or inferior vena cava.[17] Flank ecchymosis
(appearance of a bruise) is a sign of retroperitoneal bleeding, and is also called Grey Turner's sign.[15][18]
Aortic aneurysm rupture may be mistaken for the pain of kidney stones, muscle related back pain.[4]

Causes
The exact causes of the degenerative process remain unclear. There are, however, some hypotheses and welldefined risk factors.[19]
Tobacco smoking: Greater than 90% of people who develop a AAA have smoked at some point in their
life.[20]
Alcohol and hypertension: The inflammation caused by prolonged use of alcohol and hypertensive effects
from abdominal edema which leads to hemorrhoids, esophageal varices, and other conditions, is also
considered a long-term cause of AAA.
Genetic influences: The influence of genetic factors is high. AAA is 4-6 times more common in male
siblings of known patients, with a risk of 20-30%.[21] The high familial prevalence rate is most notable in
male individuals.[22] There are many hypotheses about the exact genetic disorder that could cause higher
incidence of AAA among male members of the affected families. Some presumed that the influence of
alpha 1-antitrypsin deficiency could be crucial, while other experimental works favored the hypothesis of
X-linked mutation, which would explain the lower incidence in heterozygous females. Other hypotheses
of genetic etiology have also been formulated.[15] Connective tissue disorders, such as Marfan syndrome
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and Ehlers-Danlos syndrome, have also been strongly associated with AAA.[17] Both relapsing
polychondritis and pseudoxanthoma elasticum may cause abdominal aortic aneurysm.[23]
Atherosclerosis: The AAA was long considered to be caused by atherosclerosis, because the walls of the
AAA are frequently affected heavily. However, this hypothesis cannot be used to explain the initial defect
and the development of occlusion, which is observed in the process.[15]
Other causes of the development of AAA include: infection, trauma, arteritis, cystic medial necrosis (m.
Erdheim).[17]

Pathophysiology
The most striking histopathological changes of aneurysmatic aorta are
seen in tunica media and intima. These include accumulation of lipids in
foam cells, extracellular free cholesterol crystals, calcifications,
thrombosis, and ulcerations and ruptures of the layers. There is an
adventitial inflammatory infiltrate.[17] However, the degradation of
tunica media by means of proteolytic process seems to be the basic
pathophysiologic mechanism of the AAA development. Some
researchers report increased expression and activity of matrix
metalloproteinases in individuals with AAA. This leads to elimination of
elastin from the media, rendering the aortic wall more susceptible to the
influence of the blood pressure.[15] Others reports have suggested the
serine protease granzyme B may contribute to aortic aneurysm rupture
through the cleavage of decorin leading to disrupted collagen
organization and tensile strength of the adventitia.[24][25] There is also a
reduced amount of vasa vasorum in the abdominal aorta (compared to
the thoracic aorta); consequently, the tunica media must rely mostly on
diffusion for nutrition which makes it more susceptible to damage.[26]

A plate from Gray's Anatomy with


yellow lines depicting the most
common infrarenal location of the
AAA.

Hemodynamics affect the development of AAA. It has a predilection for the infrarenal aorta. The histological
structure and mechanical characteristics of infrarenal aorta differ from those of the thoracic aorta. The diameter
decreases from the root to the bifurcation, and the wall of the abdominal aorta also contains a lesser proportion
of elastin. The mechanical tension in abdominal aortic wall is therefore higher than in the thoracic aortic wall.
The elasticity and distensibility also decline with age, which can result in gradual dilatation of the segment.
Higher intraluminal pressure in patients with arterial hypertension markedly contributes to the progression of
the pathological process.[17] Suitable hemodynamics conditions may be linked to specific intraluminal thrombus
(ILT) patterns along the aortic lumen, which in turn may affect AAA's development.[27]

Diagnosis
An abdominal aortic aneurysm is usually diagnosed by physical exam, ultrasound, or CT. Plain abdominal
radiographs may show the outline of an aneurysm when its walls are calcified. However, this is the case in less
than half of all aneurysms. Ultrasonography is used to screen for aneurysms and to determine the size of any
present. Additionally, free peritoneal fluid can be detected. It is noninvasive and sensitive, but the presence of
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bowel gas or obesity may limit its usefulness. CT scan has a nearly 100% sensitivity for aneurysm and is also
useful in preoperative planning, detailing the anatomy and possibility for endovascular repair. In the case of
suspected rupture, it can also reliably detect retroperitoneal fluid. Alternative less often used methods for
visualization of the aneurysm include MRI and angiography.
An aneurysm ruptures if the mechanical stress (tension per area) exceeds the local wall strength; consequently,
peak wall stress (PWS)[28] and peak wall rupture risk (PWRR)[29] have been found to be more reliable
parameters than diameter to assess AAA rupture risk. Medical software allows computing these rupture risk
indices from standard clinical CT data and provides a patient-specific AAA rupture risk diagnosis.[30] This type
of biomechanical approach has been shown to accurately predict the location of AAA rupture.[31]

A ruptured AAA with


an open arrow marking
the aneurysm and the
closed arrow marking
the free blood in the
abdomen

Sagittal CT image of an
AAA.

Biomechanical AAA
Rupture risk prediction.

Ultrasound image of a
normal abdominal aorta
measuring 1.9 cm in
diameter.

The faint outline of the


calcified wall of a AAA
as seen on plain X-ray

Abdominal aortic
aneurysms (3.4 cm)

An axial contrast
enhanced CT scan
demonstrating an
abdominal aortic
aneurysm of 4.8 by
3.8 cm

Classification

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Abdominal aortic aneurysms are commonly divided according to their size and symptomatology. An aneurysm
is usually defined as an outer aortic diameter over 3 cm (normal diameter of the aorta is around 2 cm).[32] If the
outer diameter exceeds 5.5 cm, the aneurysm is considered to be large.[33] A ruptured AAA is a clinical
diagnosis involving the presence of the triad of abdominal pain, shock and a pulsatile abdominal mass. If these
conditions are present, indicating AAA rupture, no further clinical investigations are needed before surgery.[34]

Prevention
Smoking cessation
Treatment of hypertension

Screening
The U.S. Preventive Services Task Force recommends a single screening ultrasound for abdominal aortic
aneurysm in males age 65 to 75 years who have a history of smoking.[7] There is an estimated number needed
to screen of approximately 850 people.[35] It is unclear if screening is useful in women aged 65 to 75 who have
smoked and they recommend against screening in women who have never smoked.[7]
Repeat ultrasounds should be carried out in those who have an aortic size greater than 3.0 cm.[36] In those
whose aorta is between 3.0 and 3.9 cm this should be every three years, if between 4.0 and 4.4 cm every two
year, and if between 4.5 and 5.4 cm every year.[36]
In the United Kingdom one time screening is recommended in all males over 65 years of age.[2]

Management
The treatment options for asymptomatic AAA are conservative management, surveillance with a view to
eventual repair, and immediate repair. There are currently two modes of repair available for an AAA: open
aneurysm repair (OR), and endovascular aneurysm repair (EVAR). An intervention is often recommended if the
aneurysm grows more than 1 cm per year or it is bigger than 5.5 cm.[20] Repair is also indicated for
symptomatic aneurysms.[37]

Conservative
Conservative management is indicated in patients where repair carries a high risk of mortality and in patients
where repair is unlikely to improve life expectancy. The mainstay of the conservative treatment is smoking
cessation.
Surveillance is indicated in small asymptomatic aneurysms (less than 5.5 cm) where the risk of repair exceeds
the risk of rupture. As an AAA grows in diameter the risk of rupture increases. Surveillance until the aneurysm
has reached a diameter of 5.5 cm has not been shown to have a higher risk as compared to early
intervention.[38][39]
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Medication
No medical therapy has been found to be effective at decreasing the growth rate or rupture rate of asymptomatic
AAAs.[2] Blood pressure and lipids should however be treated per usual.[32]

Surgery
Surgery for an abdominal aortic aneurysm is known as AAA surgery or AAA repair.
The threshold for repair varies slightly from individual to individual, depending on the balance of risks and
benefits when considering repair versus ongoing surveillance. The size of an individual's native aorta may
influence this, along with the presence of comorbidities that increase operative risk or decrease life
expectancy.[37] Evidence; however, does not support repair if the size is between 4 cm and 5.5 cm.[40]
Open repair
Open repair is indicated in young patients as an elective procedure, or in growing or large, symptomatic or
ruptured aneurysms. The aorta must be clamped off during the repair, denying blood to the abdominal organs
and sections of the spinal cord; this can cause a range of complications. It is essential to make the critical part of
the operation fast, so the incision is typically made large enough to facilitate the fastest repair. Recovery after
open AAA surgery takes significant time. The minimums are a few days in intensive care, a week total in the
hospital and a few months before full recovery.
Endovascular repair
Endovascular repair first became practical in the 1990s and although it is
now an established alternative to open repair, its role is yet to be clearly
defined. It is generally indicated in older, high-risk patients or patients
unfit for open repair. However, endovascular repair is feasible for only a
proportion of AAAs, depending on the morphology of the aneurysm.
The main advantages over open repair are that there is less perioperative mortality, less time in intensive care, less time in hospital
overall and earlier return to normal activity. Disadvantages of
endovascular repair include a requirement for more frequent ongoing
hospital reviews, and a higher chance of further procedures being
required. According to the latest studies, the EVAR procedure does not
offer any benefit for overall survival or health-related quality of life
compared to open surgery, although aneurysm-related mortality is
lower.[41][42][43][44] In patients unfit for open repair, EVAR plus
conservative management was associated with no benefit, more
complications, subsequent procedures and higher costs compared to

Abdominal aortic endoprosthesis, CT


scan, original aneurysm marked in
blue.

conservative management alone.[45] Endovascular treatment for


paraanastomotic aneurysms after aortobiiliac reconstruction is also a possibility.[46]

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Rupture
In those with aortic rupture of the AAA, treatment is immediate surgical repair. There appears to be benefits to
allowing permissive hypotension and limiting the use of intravenous fluids during transport to the operating
room.[47]

Prognosis
Although the current standard of
determining rupture risk is based
on maximum diameter, it is known
that smaller AAAs that fall below
this threshold (diameter<5.5 cm)
may also rupture, and larger AAAs
(diameter>5.5 cm) may remain
stable.[50][51] In one report, it was
shown that 1024% of ruptured
AAAs were less than 5 cm in

AAA Size (cm) Growth rate (cm/yr)[48] Annual rupture risk (%)[49]
3.0-3.9

0.39

4.0-4.9

0.36

0.5-5

5.0-5.9

0.43

3-15

6.0-6.9

0.64

10-20

>=7.0

20-50

diameter.[51] It has also been reported that of 473 non-repaired AAAs examined from autopsy reports, there
were 118 cases of rupture, 13% of which were less than 5 cm in diameter. This study also showed that 60% of
the AAAs greater than 5 cm (including 54% of those AAAs between 7.1 and 10 cm) never experienced
rupture.[52] Vorp et al. later deduced from the findings of Darling et al. that if the maximum diameter criterion
were followed for the 473 subjects, only 7% (34/473) of cases would have succumbed to rupture prior to
surgical intervention as the diameter was less than 5 cm, with 25% (116/473) of cases possibly undergoing
unnecessary surgery since these AAAs may never have ruptured.[52]
Alternative methods of rupture assessment have been recently reported. The majority of these approaches
involve the numerical analysis of AAAs using the common engineering technique of the finite element method
(FEM) to determine the wall stress distributions. Recent reports have shown that these stress distributions have
been shown to correlate to the overall geometry of the AAA rather than solely to the maximum
diameter.[53][54][55] It is also known that wall stress alone does not completely govern failure as an AAA will
usually rupture when the wall stress exceeds the wall strength. In light of this, rupture assessment may be more
accurate if both the patient-specific wall stress is coupled together with patient-specific wall strength. A noninvasive method of determining patient-dependent wall strength was recently reported,[56] with more traditional
approaches to strength determination via tensile testing performed by other researchers in the field.[57][58][59]
Some of the more recently proposed AAA rupture-risk assessment methods include: AAA wall stress;[28][60][61]
AAA expansion rate;[62] degree of asymmetry;[55] presence of intraluminal thrombus (ILT);[63] a rupture
potential index (RPI);[64][65] a finite element analysis rupture index (FEARI);[66] biomechanical factors coupled
with computer analysis;[67] growth of ILT;[68] geometrical parameters of the AAA;[69] and also a method of
determining AAA growth and rupture based on mathematical models.[70][71]

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The post-operative mortality for an already ruptured AAA has slowly decreased over several decades but
remains higher than 40%.[34] However, if the AAA is surgically repaired before rupture, the post-operative
mortality rate is substantially lower: approximately 1-6%.[72]

Epidemiology
The occurrence of AAA varies by ethnicity. In the United Kingdom the rate of AAA in Caucasian men older
than 65 years is about 4.7%, while in Asian men it is 0.45%.[73] It is also less common in individuals of
African, and Hispanic heritage.[2] They occur four times more often in men than women.[2]
There are at least 13000 deaths yearly in the U.S. secondary to AAA rupture.[2] The peak number of new cases
per year among males is around 70 years of age, the percentage of males affect over 60 years is 2-6%. The
frequency is much higher in smokers than in non-smokers (8:1), and the risk decreases slowly after smoking
cessation.[74] In the U.S., the incidence of AAA is 2-4% in the adult population.[15]
Rupture of the AAA occurs in 1-3% of men aged 65 or more, the mortality is 70-95%.[33]

History
The first historical records about AAA are from Ancient Rome in the 2nd century AD, when Greek surgeon
Antyllus tried to treat the AAA with proximal and distal ligature, central incision and removal of thrombotic
material from the aneurysm. However, attempts to treat the AAA surgically were unsuccessful until 1923. In
that year, Rudolph Matas (who also proposed the concept of endoaneurysmorrhaphy), performed the first
successful aortic ligation on a human.[75] Other methods that were successful in treating the AAA included
wrapping the aorta with polyethene cellophane, which induced fibrosis and restricted the growth of the
aneurysm. Albert Einstein was operated on by Rudolph Nissen with use of this technique in 1949, and survived
five years after the operation, though he eventually died when the aneurysm ruptured.[76] Endovascular
aneurysm repair was first performed in the late 1980s and has been widely adopted in the subsequent decades.
Endovascular repair was first used for treating a ruptured aneurysm in Nottingham in 1994[77]
Former presidential candidate Bob Dole had an abdominal aortic aneurysm in 2001 and was treated surgically
by vascular surgeon Kenneth Ouriel. The operation was successful. In 1993, country music singer Conway
Twitty died from AAA, and actor George C. Scott also died of an Abdominal Aneurysm.[78]

Society and culture


In 2001 former presidential candidate Bob Dole underwent surgery for an abdominal aortic aneurysm in which
a team of surgeons led by Doctor Kenneth Ouriel inserted a stent graft:

Ouriel said that the team inserted a Y-shaped tube through an incision in Dole's leg and placed it
inside the weakened portion of the aorta. The aneurysm will eventually contract around the
stent, which will remain in place for the rest of Dole's life.[78]

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Associated Press

Actor Robert Jacks, who plays Leatherface in Texas Chainsaw Massacre: The Next Generation died from an
abdominal aneurysm on August 8, 2001, just one day shy of his 42nd birthday. His father also died from the
same cause when Robert was a child.

Research
Risk assessment
There have been many calls for alternative approaches to rupture-risk assessment over the past number of years,
with many believing that a biomechanics-based approach may be more suitable than the current diameter
approach. Numerical modelling is a valuable tool to researchers allowing approximate wall stresses to be
calculated, thus revealing the rupture potential of a particular aneurysm. Experimental models are required to
validate these numerical results, and provide a further insight into the biomechanical behaviour of the AAA. In
vivo, AAAs exhibit a varying range of material strengths[79] from localised weak hypoxic regions[80] to much
stronger regions and areas of calcifications.[81]

Experimental models
Experimental models can now be manufactured using a novel technique involving the injection-moulding lostwax manufacturing process to create patient-specific anatomically correct AAA replicas.[82] Work has also
focused on developing more realistic material analogues to those in vivo, and recently a novel range of siliconerubbers was created allowing the varying material properties of the AAA to be more accurately represented.[83]
These rubber models can also be used in a variety of experimental testing from stress analysis using the
photoelastic method[84] to deterimining whether the locations of rupture experimentally correlate with those
predicted numerically.[85] New endovascular devices are being developed that are able to treat more complex
and tortuous anatomies.[86]

Prevention and treatment


An animal study showed that removing a single protein prevents early damage in blood vessels from triggering
a later-stage, complications. By eliminating the gene for a signaling protein called cyclophilin A (CypA) from a
strain of mice, researchers were able to provide complete protection against abdominal aortic aneurysm.[87]
Other recent research identified Granzyme B (GZMB) (a protein-degrading enzyme) to be a potential target in
the treatment of abdominal aortic aneurysms. Elimination of this enzyme in mice models both slowed the
progression of aneurysms and improved survival.[88][89]

References
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2. Kent KC (27 November 2014). "Clinical practice. Abdominal aortic aneurysms.". The New England Journal of Medicine
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External links
Cochrane Peripheral Vascular Diseases Review Group (http://pvd.cochrane.org/welcome)
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Deaths from abdominal aortic aneurysm
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