2. PATIENT CASE
52 y/o male presenting to MMC for an elective
abdominal aortic aneurysm (AAA) repair.
Presentation Labs/Vitals
Palpable pulsitile mass in Temp: 36.7 C
the epigastric area HR: 62
Intermittent abdominal pain RR: 16
Abdominal CT BP: 117/83
7.9 cm AAA
Large mural thrombus 146 4.2 6
116
completely occluding 106 28.8 0.79
the vessel lumen
3. PATIENT CASE
52 y/o male presenting to MMC for an elective
abdominal aortic aneurysm (AAA) repair.
PMH Meds
1. AAA (Dx in 2010) Tramadol
2. Hypertension Simvastatin
3. Hyperlipidemia Amlodipine
4. Depression Metoprolol
5. Intermittent claudication Zolpidem
6. Smoking
4. PATIENT CASE
52 y/o male presenting to MMC for an elective
abdominal aortic aneurysm (AAA) repair.
5. PATHOPHYSIOLOGY
AAAs develop as a result of chronic aortic wall
inflammation 4
Arterial injury
Hypertension
Hyperlipidemia
Toxins (nicotine)
Inflammation
Degradation of elastin
AAA growth & rupture
6. 7
EPIDEMIOLOGY
>32,000 cases in the U.S. every year
75% of aneurysms ≥4 cm in diameter can be
positively liked to a history of smoking
♂ Men are at 4-6 times greater risk of
developing an AAA
Incidence increases with age
Affects 2-5% of men >50 yrs; Rare in patients <50 yrs
Positive family history of AAA can
double the risk
7. 2,7
PRESENTATION
Most AAAs are small and are discovered incidentally
Insidious development, rarely causing symptoms
Symptoms
Pain
Dull, vague pain in the abdomen, back, or flank
Can be acute and severe in ruptured AAAs
Mass
Sensation of a pulsitile mass in the abdomen
Hypotension
Usually manifesting as syncope
Occuring in cases of ruptured AAAs
8. 2
PRESENTATION
Associated complications
Diminished femoral pulses
"Blue Toe" Syndrome
D/t microemboli from aortic
thrombus
Duodenal obstruction
leading to vomiting and
weight loss
Vertebral body erosion
leading to severe back pain
9. PRESENTATION
Risk of rupture AAA Diameter Rupture risk 5
is dependent on… (cm) (%/yr)
<4 0
Diameter 4-5 0.5-5
Shape 5-6 3-15
(Fusiform < Saccular) 6-7 10-20
7-8 20-40
Growth rate >8 30-50
Repair is recommended for… 6
Fusiform AAAs ≥ 5.5 cm in diameter
Pts presenting w/ back or abdominal pain
11. TREATMENT
AAA Diagnosed
Small/Stable AAA
Large/Unstable AAA
Ruptured AAA
Surveillance
Surgery
6
Goal:
Slow the rate of AAA growth such that it
does not reach the threshold for rupture
within the patient’s lifetime
12. TREATMENT SURVEILLANCE
Smoking Cessation Recommended Strong High
The single, most important modifiable risk-factor
12
Review Human (N>3 million) Smoking was associated with a 3- to 6-fold
increased risk of an aortic aneurysm
Statins Recommended Weak Low
16
Observational AAA patients Statin use was associated with a
(N=150) significantly decreased rate of AAA growth
(1.16 mm/yr less than non-users).
17
Observational AAA patients Statin use was associated with significantly
(N=130) less AAA growth at an average follow-up of
4 years (p<0.001)
13. TREATMENT SURVEILLANCE
ACE Inhibitors Insufficient Ev idence Weak Low
10
Observational AAA patients Use of ACE inhibitors was less frequent in
(N=15,326) patients who presented to the hospital
with a ruptured AAA.
Doxycycline & Insufficient Ev idence Weak Low
Roxithromycin
1
Experimental AAA patients Doxycycline 6-mo course significantly
(N=36) reduced mean MMP-9 levels
13
RCT AAA patients Aneurysm expansion was significantly
(N=32) slower in the doxycycline group at >6 mo.
18
RCT AAA patients Aneurysm expansion was significantly
(N=92) slower in the roxithromycin group over the
first year
14. TREATMENT SURVEILLANCE
Beta-Blockers NOT Recommended Weak Low
11
Observational AAA patients Patients receiving a beta-blocker had a
(N=27) significantly slower rate of AAA growth.
9
Observational AAA patients Patients receiving a beta-blocker had a
(N=121) significantly slower (p=0.02) rate of AAA
growth.
20
RCT AAA patients Patients receiving propranolol had a non-
(N=548) statistically-significant difference in AAA
growth rate (p=0.11) and mortality (p=0.36)
19
RCT AAA patients Patients receiving propranolol had a non-
(N=477) statistically-significant difference in AAA
growth rate (p=0.48)
15. 6
TREATMENT SURGERY
Pre-Operative
Antibiotic prophylaxis
1st or 2nd generation cephalosporin or vancomycin
Within 30 minutes of incision
Continued for no more than 24 hours post-op
Post-Operative
Analgesia
Epidural or PCA after an open AAA repair
DVT prophylaxis
SCDs and early ambulation for all patients
Anticoagulant therapy for patients at high risk of
developing a DVT
17. 8
TREATMENT SURGERY
Beta-blockers, statins, alpha-2
agonists, and calcium channel blockers to
reduce cardiac risk
Pain management
VTE prophylaxis
Glucose control
Post-operative arrhythmias
Beta-blockers are the preferred agent for patients with
a post-operative supraventricular arrhythmia
Cardioversion is only recommended in hemodynamically
unstable patients
18. TREATMENT SURGERY
No guideline-supported recommendations
for post-operative hyper- or hypotension
after AAA repair.
Typically, a MAP that differs from pre-operative readings
by >20% should be treated. 15
19. PATIENT CASE
4/17 OR for AAA repair. Aortic bifemoral bypass graft
placed. BP managed with nitroprusside drip.
4/19 Pt extubated and off sedation and nitroprusside.
4/20 Pt desatted and was reintubated. W/u revealed CAP
and L-sided PTX. EKG revealed pt was in a-fib w/
RVR. Abx for CAP and metoprolol for a-fib.
4/23 Pt extubated and recovering from CAP.
4/25 Pt back to NSR. Out to floor.
4/27 Discharged to home.
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Editor's Notes
“Leriche syndrome” - An atherosclerotic occlusive condition involving the abdominal aorta and/or both of the iliac arteries
Most AAAs occur in the infrarenal portion of the aorta. The aorta bifurcates into the L and R iliac arteries at approximately the level of the umbilicus and L4, and these AAAs can be palpated through the abdominal wall just above this point.