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Aortic Aneurysm. Tintinalli Chap. 62. Epidemiology. D ilation of the abdominal aorta > 3cm and consists of all layer of the aorta 15,000 deaths annually in the US 97% occur between the renal arteries and inferior mesenteric artery

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aortic aneurysm

Aortic Aneurysm

Tintinalli Chap. 62

epidemiology
Epidemiology
  • Dilation of the abdominal aorta > 3cm and consists of all layer of the aorta
  • 15,000 deaths annually in the US
  • 97% occur between the renal arteries and inferior mesenteric artery
  • Clinically important aneurysms over 4 cm in diameter are present in about 1 percent of men between the ages of 55 and 64; the prevalence increases by 2 to 4 percent per decade thereafter
  • Smoking is the greatest risk factor for aneuryms (OR 5.07) & also aneurysm growth rate
  • 5 x more likely in men
  • CAD & PVD are significant risk factors
  • HTN is a small risk factor (OR 1.15)
  • 1st degree blood relative increases odds by 4.3-fold
pathogenesis
Pathogenesis
  • Combination of genetic, structural & metabolic factors
    • Genetic predisposition
    • Increased levels of elastase/collagnase
    • Loss of blood vessel elastin
    • Copper deficiency
    • Infection (mycotic aneurysms)
    • Inflammatory disorders
    • Local Mechanical forces
clinical presentation
Clinical Presentation
  • Non-ruptured are usually incidental findings
  • Two most common findings of recent expansion: abdominal/ back pain & tender to palpation (usually epigastric region)
  • Pulsatile & tender mass is highly suggestive of recent rupture (found in 77% of ruptures)
  • Bruits over aorta or femoral arteries
  • Unequal distal pulses
  • Presentation mimics numerous common ED diagnoses
diagnosis
Diagnosis
  • Sensitivity of physical examination for the detection of an abdominal aortic aneurysm ranges from 22 to 96 percent
  • Most non-ruptured aneurysms are incidental findings
  • Plain abdominal films: 75% have suspicious findings
    • Aneurysmal calcification, loss of renal shadow, soft tissue mass
  • Real-time ultrasonography is the preferred modality for screening and for assessing and following abdominal aortic aneurysms since the sensitivity approaches 100 percent, not good at detecting ruptures
  • CT with contrast: sensitivity around 100% and can detect rupture plus alternative diagnoses
treatment
Treatment
  • Mortality rate on elective repair 5%
  • Mortality rate on emergency repair of ruptured aneurysms 50%
  • Risk of Rupture (5 cm is the usual surgical cutoff)
    • Zero in aneurysms less than 4.0 cm in diameter
    • 0.5 to 5 percent for those 4.0 to 4.9 cm in diameter
    • 3 to 15 percent for those 5.0 to 5.9 cm in diameter
    • 10 to 20 percent for those 6.0 to 6.9 cm in diameter
    • 20 to 40 percent for those 7.0 to 7.9 cm in diameter
    • 30 to 50 percent for those ≥8.0 cm in diameter
treatment1
Treatment
  • Indications for surgical intervention
    • Patients with symptomatic aneurysms should undergo repair, regardless of aneurysm diameter.
    • Early repair may be beneficial in patients whose aneurysm increases ≥0.5 cm in diameter in six months.
    • Repair of suprarenal and/or thoracoabdominal aneurysms involves more extensive surgery and greater operative risk. Repair of such aneurysms may be beneficial at diameters >5.5 to 6.0 cm in diameter.
treatment2
Treatment
  • ED treatment
    • If suspected rupture
      • Two large bore Ivs
      • Type & Cross 10 units
      • Order ECG
      • Obtain immediate vascular surgery consultation