Management

• Conservative therapy
– Smoking cessation
– Lifestyle modification
• Medical therapy
– Beta blocker
– Control blood pressure
– IHD prevention
• Surgical therapy
– Conventional open aneurysm surgery
– Endovascular repair
 Overview of AAA
• An aortic aneurysm occurs when the walls of the main blood vessel
that carries blood away from the heart (the aorta) bulges or dilates.

• Abdominal aortic aneurysms are not related to aneurysms of the

blood vessels in the brain.

• Intact abdominal aortic aneurysms - no symptom

• Large aneurysms – burst, rupture, heavy bleeding

• Ruptured aortic aneurysm - medical emergency

 Risk Factors
• Male > female (4-5 times)
• White > others
• With other medical condition (coronary heart disease,
peripheral vascular disease)
• Smoking (direct related to no. of years smoking;
decrease in years when stop)
• Family history increases risk & interacts with risks assoc
with gender and age
• Brothers of a person with a known aneurysm >60 year
old (18%)
 Screening
• Abdominal ultrasound (US)
• Recommended group
– Men (65 – 75 y/o) + have ever smoked = at least once
– Men (> 75 y/o) - unlikely to benefit from screening
– Men (>60 y/o) + a sibling or parent with AAA =
physical examination + ultrasound screening.
– No recommendation to screen women for AAA
– Women concern about risk of AAA, based upon their
family history or other risk factors = discuss
 Symptoms
• Usually asymptomatic
• If noticeable – pulsating mass near navel (30%
discovered by doc)
• Other – U/S, Xray
• Abdominal pain
• Back pain
• Little warning before rupture
• Pain / tenderness had recent increase in aneurysm
size – predict rupture
 Risk of Rupture
• The risk of rupture of AAA depends upon the size of the
aneurysm and the rate at which it is expanding.
• The evidence suggests that aneurysms expand at a rate of about
0.3 - 0.4cm per year.
• The annual risk of rupture based upon aneurysm size is
estimated as follows:
– <4.0 cm in diameter = No risk of rupture
– 4.0 - 4.9 cm in diameter = 0.5 to 5 percent
– 5.0 - 5.9 cm in diameter = 3 to 15 percent
– 6.0 - 6.9 cm in diameter = 10 to 20 percent
– 7.0 - 7.9 cm in diameter = 20 to 40 percent
– ≥ 8.0 cm in diameter = 30 to 50 percent
 Treatment
• Successful rate for ruptured AAA is much more
lower than elective surgery
• Goal of therapy is to prevent rupture
• Primary treatment for AAA is surgery
• Risk of surgery for AAA should be balanced
with risk of rupture of untreated AAA
• Larger aneurysms tend to expand faster than smaller aneurysms.
• Aneurysms that expand rapidly (for example, more than 0.5 cm
over six months) are at high risk of rupture.
• Growth
– more rapid in smokers
– less rapid in patients with diabetes mellitus or peripheral arterial
disease
• Some aneurysms, for unclear reasons, remain relatively fixed in
size for a period of time and then undergo rapid expansion.
• The risk of rupture of large aneurysms (≥5 cm) is significantly
greater in women than men (18 versus 12 percent)
 Treatment Consideration
• Aneurysm <4cm in diameter
– No immediate surgery
– Watchful waiting
– Follow up with ultrasound every 6 months
• 4-5.5cm
– Consider the risks of rupture
• Size and rate of growth
• Symptoms
• Extend of vascular diseases; aneurysm in other arteries
• >5.5cm in diameter / 0.5cm over 6 month period
– Surgery (if fit)
• 2 times size for normal portion of aorta
• Surgery may not possible for patient with serious heart or lung diseases
 Conservative and Medical Treatment
• Watch for abdominal pain and tenderness at the
back – indicate impending leaking (emergency
attention)
• Smoking cessation
• Lifestyle modification
• Control blood pressure and blood sugar level
• Beta blocker
– Control blood pressure and coronary artery disease
– Advantages over the enlargement of the aneurysm
 Surgical Intervention
Conventional therapy Endovascular therapy
Mortality Approx 5% 1.7%
Length of Hospital Stay 7-10 days 2-4 days
ICU/HDW care Yes No
Cost Slightly less expensive More expensive
Anatomical Constraints Distant between AAA and Needs 15mm of relative
renal arteries can be normal aorta below renals
<15mm

Past Med History More difficult with Unaffected by previous

previous surgery and surgery
peritonitis

Follow Up Discharge at 3 months. Frequent CT and U/S for

Rescan after 5-7 years. life. Reintervention rates
Reintervention unlikely high but improving
• Conventional open aneurysm surgery
– Standard approach: long midline / transverse abdominal
incision
– Preoperative anticoagulant (IV heparin): prevent distal
thrombosis
– Clamp: iliac arteries + infrarenal aorta
– Longitudinal incision
– 2 grafts
• Straight tube graft
• Bifurcation graft (‘trouser graft’)
– Suture (Technique: inlay grafting)
• Prevent aorto-intestinal fistula
• Proximal, within sac, distal
• Endovascular aneurysm repair (EVAR)
– Achieved by transfemoral or transiliac placement of prosthetic
graft
– Proximal and distal cuffs / stents anchor graft
– Exclude aneurysm from circulation
– 3 main types of graft
• Aorto-aortic
• Bifurcated aorto-iliac
• Aorto-uniiliac graft with femoro-femoral crossover and contralateral
iliac occlusion
– Use of technique depends on aneurysm morphology
– Aneurysm morphology is best assessed with spiral CT
– 40% of aneurysms suitable for this type of repair
– Still has 1% per year risk of aneurysm rupture
– Can be for ruptured aneurysms
 Complications of Surgery
• Death - 1.8-5% if elective and 50% if ruptured
• Pneumonia - 5%
• Myocardial infarction - 2-5%
• Groin infection - Less than 5%
• Graft infection - Less than 1%
• Colon ischemia - Less than 1% if elective and 15-20% if ruptured
• Renal failure related to preoperative creatinine level, intraoperative cholesterol embolization,
and hypotension
• Incisional hernia - 10-20%
• Bowel obstruction
• Amputation from major arterial occlusion
• Blue toe syndrome and cholesterol embolization to feet
• Impotence in males - Erectile dysfunction and retrograde ejaculation (>30%)
• Paresthesias in thighs from femoral exposure (rare)
• Lymphocele in groin - Approximately 2%
• Late graft enteric fistula