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Abdominal

Aor,c Aneurysm

Dr. Akhmadu, SpB(K)V, PhD



1. Divisi Vascular dan Endovascular, Departemen Ilmu Bedah
Fakultas Kedokteran Universitas Indonesia,
RSUPN Ciptomangunkusumo, Jakarta
2. Bedah Vaskuler dan Endovaskuler, RSU Hermina, Bekasi
ABDOMINAL AORTIC ANEURYSMS

Do you know
how we lost one of the
greatest minds in history?

2006 Medtronic, Inc. All rights reserved. This presentation is for international use only, products not available for sale in the USA. UC200702115EE.
SILENT KILLER
Deni&on
An aneurysm is a permanent and irreversible dilata&on of a blood vessel by at
least 50% of the normal expected diameter.

An aneurysm is caused by degrada&on of the elas&c lamellae, a leukocy&c


inltrate, enhanced proteolysis and smooth muscle cell loss.

The 'normal' diameter of the abdominal aorta is approximately 2 cm; it increases
with age.

An abdominal aneurysm is usually dened as an aor&c diameter of 3 cm or


greater.

Large and life-threatening AAAs are preceded by a long period of subclinical


growth in the diameter of the aneurysm (about 1-6 mm/year on average).

The larger the AAA, the higher its growth rate and greater the risk of rupture. The
risk of rupture is also greater for women.
Pathophysiology of a AAA
Pathological changes cause the
aorta wall to:
Become thinner
Bulge
Tear
Rupture
Pathophysiology of a AAA aneurysm growth

AAA growth:
Expansion tends to be highly
variable
AAA growth accelerates with
the diameter of the AAA
Aneurysm growth is inuenced
by risk factors
What are the sta&s&cs on AAA in Asia?

Only 17,000 in Asia are es&mated to be diagnosed


with AAA each year.

Over 22,000 pa&ents have aor&c repairs each


year.

Up to 50% of pa&ents with untreated aneurysms


>5.5 cm will die of rupture in a 5-year period.

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Risk Factors
Atherosclero&c disease : stroke, coronary artery disease, peripheral artery disease

Family history - there are probably strong gene&c factors.

Tobacco smoking is an important factor.

Male sex.

Increasing age.

Hypertension.

Chronic obstruc&ve pulmonary disease.

Hyperlipidaemia.
Unruptured AAA
NO SYMPTOMS
AAA may be an incidental nding on clinical examina&on, or on
scans - ultrasound, CT or MRI. It may some&mes be visible on a
plain X-ray lm.

Possible symptoms and signs are:


Pain in the back, abdomen, loin or groin:
This may be due to pressure on nearby structures. Back pain may be due to
erosion of the vertebral bodies.
NB: severe lumbar pain of recent onset may indicate impending rupture.
The pa&ent or doctor may nd a pulsa&le abdominal swelling
Distal embolisa&on may produce features of limb ischaemia.
Ureterohydronephrosis can also occur with AAA.
Ruptured AAA
NB: the diagnosis may not be obvious.

The opera&ve mortality of trea&ng a ruptured aneurysm is 30-70%.

Ruptured AAA should be considered in any pa&ent with hypotension and


atypical abdominal symptoms.
Similarly, abdominal pain in a pa&ent with a known aneurysm or pulsa&le
mass must be considered as a possible ruptured or rapidly expanding
aneurysm and treated accordingly.

Ruptured AAA may present with:


Pain in the abdomen, back or loin - the pain may be sudden and severe.
Syncope, shock or collapse
Ruptured AAAs are fatal in 82% of cases
2006 Medtronic, Inc. All rights reserved. This presentation is for international use only, products not available for sale in the USA. UC200702114EE.

Mortality is high due to


rapid circulatory collapse.

Less than 50% of emergency


cases arrive at the hospital
alive; out of those,
only 50%
survive
conven&onal Ruptured AAA

AAA repair.
Examina&on

Sensi&vity is reduced with increasing waist size.

There may be an abdominal bruit.

Clinical signs vary according to the whether the aneurysm


compresses other structures or ruptures - and, if ruptured,
the site and extent of bleeding.

Retroperitoneal haemorrhage may cause Grey Turner's


sign, ie ank bruising.
Inves&ga&on
Ultrasound is simple and cheap
It is an extremely sensi&ve test.
It is painless and
non-invasive.
It is cost-eec&ve.

CT provides more anatomical details - eg, it can show the


visceral arteries, mural thrombus, the 'crescent sign' (blood
within the thrombus, which may predict imminent rupture)
and para-aor&c inamma&on.
Management
Surgical (open) repair:
This is the tradi&onal opera&on. It involves exposure of the
abdominal aorta, aor&c and iliac clamping and replacement of
the aneurysmal segment with a prosthe&c graf.

Endovascular repair of AAA:


Endovascular aneurysm repair (EVAR) involves introducing a
stent-graf system through the femoral arteries, which relines
the aneurysm, diverts blood ow through the endograf and
allows the aneurysm to thrombose.

Currently, about 65% of pa&ents with AAA are suitable for


endovascular repair.
2 Treatment Op&ons

Open Surgery Endovascular


Endovascular:
Benets
Minimally invasive
Reduced risk of death
Faster recovery
Improved func&onal outcomes
Prognosis
Natural history
The risk of rupture is mainly determined by aneurysm diameter.
The natural history of small AAA is gradual expansion at an annual rate of approximately 10%
of the ini&al arterial diameter.
People with aor&c aneurysms are at increased risk of cardiovascular events, mostly unrelated
to the aneurysm.

Elec,ve repair
Overall mortality in the UK is 2.4% for elec&ve AAA repair. There is an inverse rela&onship
between opera&ve mortality and the number of cases performed in individual hospitals, with
many specialist centres repor&ng mortality rates well below 52%.

The mortality rate of aneurysm repair depends on the pa&ent's tness for surgery and the
morphology of the aneurysm.

Pa&ents with severe cardiorespiratory or renal disease may have high peri-opera&ve
mortality rates, and for them the threshold for elec&ve repair may be set at a larger
aneurysm diameter.
Without surgery
The annual survival rate is only 20% for aneurysms
larger than 5 cm.

Ruptured AAA
Risk of rupture increases with aneurysm size and
aneurysms over 6 cm have a 25% annual risk of
rupture.
The outcome is poor, with approximately 80% overall
mortality from ruptured AAA.
Most pa&ents die before reaching hospital. Surgical
repair of ruptured AAA has a mortality of around 50%.
Why is early diagnosis of AAA so important?

For elec&ve AAA cases,


the opera&ve mortality
The opera&ve mortality rate is dras&cally
of trea&ng a ruptured
reduced, approximately
aneurysm is 30-70%.
only 2-7% of cases
result in death.

AAA ruptures can be avoided by


iden,fying the popula,on at risk
and conduc,ng simple,
inexpensive ultrasound
examina,ons.

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Pa&ent Screening
High Risk Pa,ents

Risk Factors People over age 60
Male gender, 5 &mes > females
Family history of AAA
History of or currently smoking
Atherosclerosis
High blood pressure
High cholesterol
COPD
Prior CABG

Screening Physical examina,on


NOTE: May miss up to 80% of AAA if the diagnosis is limited to physical
examina>on.

Ultrasound

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Screening
Screening by ultrasound is feasible to allow
early diagnosis. The idea is to oer a single
scan to men aged 65.
If nega&ve, this eec&vely rules out AAA for life.
Mr M, 70 y.o Aorta aneurysm, EVAR
Mr H, 60 y.o, internal iliac aneurysm, covered stent
Mr H, 60 y.o Aor&c aneurysm, right iliac
aneurysm, EVAR
Mr J, 76 y.o Aor&c aneurysm, EVAR
Mr M, 72 y.o Right Common Mr M, 73 y.o Abdominal
Iliac Aneurysm Aortic Aneurysm with frog
leg common iliac
Thank you!

Questions?