Abdominal aortic aneurysm
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| Abdominal aortic aneurysm Classification and external resources | |
 | |
|---|---|
| Abdominal Aneurysm: Gross, natural color, unopened large and quite typical aneurysm extending from below renal arteries to bifurcation Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology | |
| ICD-10 | I71. |
| ICD-9 | 441 |
| OMIM | 100070 |
| DiseasesDB | 792 823 805 |
| eMedicine | emerg/942 med/2783 emerg/27 radio/1 med/3443 |
| MeSH | D001014 |
| Cardiology Network |
 Discuss Abdominal aortic aneurysm further in the WikiDoc Cardiology Network |
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Overview
Abdominal aortic aneurysm, also written as AAA and often pronounced 'triple-A', is a localized dilatation of the abdominal aorta, that exceeds the normal diameter by more than 50%. The normal diameter of the infrarenal aorta is 2cm. It is caused by a degenerative process of the aortic wall, however the exact etiology remains unknown. It is most commonly located infrarenally (90%), other possible locations are suprarenal and pararenal. The aneurysm can extend to include one or both of the iliac arteries. An aortic aneurysm may also occur in the thorax.
History
The first historical records about AAA are from Ancient Rome, more precisely from the 2nd century AD, when Greek surgeon Antyllus tried to treat the AAA with proximal and distal ligature, central incision and evacuation 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.[1] 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 Rudolf Nissen with use of this technique in 1949, and survived five years after the operation.[2]
Definition
- Aneurysm is a Greek word meaning dilatation.
- A true abdominal aortic aneursym (AAA) is a circumscribed, permanent, segmental dilatation involving the three layers of vessel wall with a minimum increase in diameter of 50% compared with the expected normal (or proximal segment)
- The aorta below the renal arteries is the most common site for true arterial aneurysms.
Overview
- The abdominal aorta tends to be 2 cm in diameter, therefore a true AAA measures 3.0 cm or more.
- The normal diameter of one's aorta depends on the patient's age, sex, height, weight, race, body surface area, and baseline blood pressure.
- Aortic ectasia is a mild generalized dilatation (<50% of the normal diameter of ≤ 2.9 cm) that is due to age-related degenerative changes in vessel wall.
- Aneurysms are usually classified by their shape:
- Fusiform aneurysms: most common type seen in the infrarenal aorta.
- Diffuse, circumferential
- Saccular aneurysms
- Involve only a portion of the circumference, with a characteristic outpouching of the vessel wall.
- Fusiform aneurysms: most common type seen in the infrarenal aorta.
Related Key Words and Synonyms:
- AAA
- Aortic ectasia
- Fusiform aneurysms
- Saccular aneurysms
Epidemiology and Demographics
AAA is uncommon in individuals of African, African American, Asian and Hispanic heritage. The frequency rate varies strongly between males and females. The peak incidence is among males around 70 years of age, the prevalence among males over 60 years totals 2-6%. The frequency is much higher in smokers than in non-smokers (8:1). Other risk factors include hypertension and male sex.[3] In the US, the incidence of AAA is 2-4% in the adult population. [4]. Rupture of the AAA occurs in 1-3% of men aged 65 or more, the mortality is 70-95%[5].
- Abdominal aortic aneurysms (AAA) is a disease of the elderly, and is the 10th leading cause of death in older men in the United States.
- An individual's risk of AAA increases by 6% per decade of life
- In a multinational study, the prevalence of AAA was four times higher in men than women.
- The prevalence is 2-5 times higher in men and 2-3 times higher in women with other cardiovascular risk factors or atherosclerotic cardiovascular diseases, than in control groups without risk factors.
- The disease tends to affect older Caucasion males
- AAA tends to cluster in families, therefore affecting younger members of families in the absence of traditional acquired risk factors.
Risk Factors
- The strongest independent acquired risk factor for AAA is smoking.
- In a study by Wilmink et. al wilminkref1, current smokers were shown to be 7.6 times more likely to have an AAA than non smokers.
- The longer one has smoked, the greater the risk for an AAA, but the number of cigarettes smoked per day did not seem to correlate with risk after adjusting for duration of smoking.
- Age and family history are the strongest nonreversible risk factors.
- The prevalence of AAAs among first-degree relatives of patients with AAAs ranges from 15-29%, compared with 2% among relatives of controls.
- Other risk factors include:
- Hypertension
- Chronic obstructive pulmonary disease
- Atherosclerotic disease in other vascular beds
- Coronary artery disease, cerebrovascular disease, peripheral artery disease.
Rapid AAA Expansion
- In small AAAs (3-5.4 cm), the expansion rate appears to be proportional to the initial diameter.
- Other factors related to rapid expansion are:
- Systolic hypertension
- Wide pulse pressure
- Ongoing smoking.
- C-reactive protein levels have also been found to be elevated in larger aneurysms, however do not appear to be linked to rapid expansion.
AAA Rupture
A ruptured AAA carries a 60 to 90% mortality before the patient reaches hospital and a 30 to 80% operative mortality for those who make it to surgery. The risk of rupture is proportional to the size and rate of growth of the aneurysm. Aneurysms greater than 5 cm diameter or that grow faster than 10 mm per year have a significantly increased risk of rupture and are indications for elective operative repair. [6] [7]
- In the UK Small Aneurysm Trial, UKref2 important independent variables were identified with abdominal aortic aneurysm rupture:
- Female sex
- AAA diameter
- Current smoker
- Mean blood pressure
- Age
- Forced expiratory volume in 1 second
- Size at diagnosis is one of the best predictors of rupture.
- The risk increases substantially when the diameter exceeds 6 cm in men and 5 cm in women.
- Small aneurysms can rupture as well
- Small aneurysms are threefold more likely to rupture in women
- Localized outpouchings seems to increase the aneurysm's vulnerability for rupture
- It has been suggested that aneurysm growth and rupture correlate with growth of the aneurysm's mural thrombus
- The part of the aneurysm wall that is covered with thrombus has been shown to be thinner and showed focal anoxia, inflammation, apoptosis of the smooth muscle cells, and degraded extracellular matrix than wall segments not covered by the thrombus.
Diagnostic Findings
 Abdominal Aortic Aneurysm |
 Abdominal Aortic Aneurysm |
 Abdominal Aortic Aneurysm |
 Abdominal Aortic Aneurysm |
 Abdominal Aortic Aneurysm |
 Abdominal Aortic Aneurysm |
 Abdominal Aortic Aneurysm |
 Abdominal Aortic Aneurysm |
Labeled images shown below are courtesy of Radswiki and copylefted.
 CT: a large abdominal aortic aneurysm |
 CT: a large abdominal aortic aneurysm |
 CT: a large abdominal aortic aneurysm |
 CT: a large abdominal aortic aneurysm |
 CT: a large abdominal aortic aneurysm |
 CT: a large abdominal aortic aneurysm |
 CT: a large abdominal aortic aneurysm |
 Ruptured abdominal aortic aneurysm |
 Ruptured abdominal aortic aneurysm |
 Ruptured abdominal aortic aneurysm |
 This patient presented with acute abdominal pain and hypotension. His non-contrast CT shows a large AAA and extensive periaortic haematoma. A thick (but subtle) hyperdense crescent is present within the aortic wall posteriorly and laterally which represents acute intramural hematoma, a sign of acute or impending rupture. (Image courtesy of Dr Donna D'Souza) |
Screening
See also Abdominal Aortic Aneurysm Screening
- It is recommended that all men age 60-85 years be screened for AAAs
- Women age 60-85 years with cardiovascular risk factors, as well as both men and women older than 50 years with a family history of AAAs.
- The US Preventive Services Task Force (USPSTF)recommends one-time screening for AAAs by ultrasonography in men age 65-75 years who have smoked at one point in their life or another. UStaskref3
A clinical practice guideline by the U.S. Preventive Services Task Force (USPSTF) 'recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men age 65 to 75 years who have ever smoked'.[8][9] This is a grade B recommendation. An re-analysis of the meta-analysis estimated a number needed to screen of approximately 850 patients.[10]
Effective January 1, 2007, provisions of the SAAAVE Act (Screening Abdominal Aortic Aneurysm Very Efficiently) now provide a free, one-time, ultrasound AAA screening benefit for those qualified seniors. Men who have smoked at least 100 cigarettes during their life, and men and women with a family history of AAA qualify for the one-time ultrasound screening.
Enrollees must visit their healthcare professional for their Welcome to Medicare physical within six months of enrollment in order to qualify for the free screening.
The Welcome to Medicare Physical Exam must be completed within the first six months of Medicare eligibility, but there is no published time limit thereafter for completion of the AAA screening. Providers who perform the physical and order the AAA screening need to document the AAA risk factors.[11]
The largest of the randomized controlled trials on which this guideline was based studied a screening program that consisted of[12]:
- Screening men ages 65-74 years (not restricted to ever smokers). 'Men in whom abdominal aortic aneurysms (> or =3 cm in diameter) were detected were followed-up... Patients with an aortic diameter of 3·0–4·4 cm were rescanned at yearly intervals, whereas those with an aortic diameter of 4·5–5·4 cm were rescanned at 3-monthly intervals ... Surgery was considered on specific criteria (diameter > or =5.5 cm, expansion > or =1 cm per year, symptoms)'.
This trial reported significant short[12] ( number needed to screen after 4 years of approximately 590 to prevent nonfatal ruptured AAA plus AAA-related deaths[13]) and long term[14] ( number needed to screen after 7 years of approximately 280 to prevent nonfatal ruptured AAA plus AAA-related deaths) benefit and cost effectiveness.[15] Subsequent randomized controlled trials also found benefit:
- number needed to screen after 4 years of 300[16]
- number needed to screen after and after 7 years of 563 (calculation).[17]
Pathophysiology & Etiology
The exact causes of the degenerative process remain unclear. There are, however, some theories and risk factors defined.
- Genetic influences: The influence of genetic factors is highly probable. The high familial prevalence rate is most notable in male individuals.[18] There are many theories 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, some experimental works favored the theory of X-linked mutation, which would explain the lower incidence in heterozygous females. Other theories of genetic etiology were also formulated.[4]
- Hemodynamic influences: Abdominal aortic aneurysm is a focal degenerative process with predilection for the subrenal aorta. The histological structure and mechanical characteristics of subrenal 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.[3]
- Atherosclerosis: The AAA was long considered to be caused by atherosclerosis, because the walls of the AAA are frequently affected heavily. However, this theory cannot be used to explain the initial defect and the development of occlusion, which is observed in the process.[4]
- Other causes: Other causes of the development of AAA include: infection, trauma, arteritis, cystic medial necrosis (m. Erdheim) and connective tissue disorders (e.g. Marfan syndrome, Ehlers-Danlos syndrome).[3]
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, ulcerations and ruptures of the layers and thrombosis. There is an adventitial inflammatory infiltrate.[3] 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 elastine from the media, rendering the aortic wall more susceptible to the influence of the blood pressure. [4] Other pathophysiological cause for development of the AAA is inflammation.
- The aortic wall has a specific arrangement of structural proteins that give it both strength and elasticity.
- The composition of the extracellular matrix protein in the media may change with age or in reponse to other conditions, therefore resulting in subsequent destruction of the elastic lamella, rendering the aorta less able to withstand the force of systolic pressure.
- The infrarenal aorta is more prone to develop aneurysms than other segments for the following reasons:
- It is the segment that must expand the most during systole and contract the most during diastole.
- It has a thinner wall, and has fewer vasa vasora than the thoracic aorta
- It is more prone to atherosclerosis, a proposed nidus for aneurysmal dilatation.
- Patients with abdominal aortic aneurysms (AAA) also have atherosclerosis in the aorta and other arteries, suggesting that aneurysmal disease may be part of a larger spectrum of vascular disease, and that atherosclerosis actually promotes AAA formation.
- In atherosclerotic AAA, inflammatory cells infiltrate into the vessel wall and may secrete specific matrix metalloproteinases (MMPs)
- The different types of MMPs play diverse roles via complex interactions that eventually lead to degradation of the structural media proteins, and subsequently to aneurysmal dilatation.
- There are significantly fewer smooth muscle cells in human AAA tissues than in normal or atherosclerotic nonaneurysmal aortic tissue.
- This decrease in smooth muscle cells in suspected to be secondary to apoptosis, therefore suggesting a role for focal cell apoptosis in the pathogenesis of AAA.
Diagnosis
AAAs are commonly divided according to their size and symptomatology. An aneurysm is usually considered to be present if the measured outer aortic diameter is over 3 cm (normal diameter of aorta is around 2 cm). The natural history is of increasing diameter over time, followed eventually by the development of symptoms (usually rupture). If the outer diameter exceeds 5 cm, the aneurysm is considered to be large. For aneurysms under 5 cm, the risk of rupture is low, so that the risks of surgery usually outweigh the risk of rupture. Aneurysms less than 5cm are therefore usually kept under surveillance until such time as they become large enough to warrant repair, or develop symptoms.[3][5] The vast majority of aneurysms are asymptomatic. The risk of rupture is high in a symptomatic aneurysm, which is therefore considered an indication for surgery. Possible symptoms include low back pain, flank pain, abdominal pain, groin pain or pulsating abdominal mass.[19] The complications include rupture, peripheral embolisation, acute aortic occlusion, aortocaval or aortoduodenal fistulae. On physical examination, a palpable abdominal mass can be noted. Bruits can be present in case of renal or visceral arterial stenosis.[4]
As most of the AAAs are asymptomatic, their presence is usually revealed during an abdominal examination for another reason - the most common being abdominal ultrasonography. A physician may also detect the presence of an AAA by abdominal palpation. Ultrasonography provides the initial assessment of the size and extent of the aneurysm, and is the usual modality for surveillance. Preoperative examinations include CT, MRI and special modes thereof, like CT/MR angiography. Angiography may be useful also, as an additional method of measurement for the planning of endoluminal repair. Note that an aneurysmal aorta may appear normal on angiogram, due to thrombus within the sac.
- Many AAAs are detected incidentally during cardiac catheterizations, computed tomography (CT), or magnetic resonance imaging (MRI) performed for unrelated reasons.
- Up to 50% of AAAs can be recognized on plain roentgenograms as a calcified aneurysmal wall.
History and Symptoms
- Most AAAs are asymptomatic and expand silently.
- Spontaneous abdominal pain in a patient with a pulsatile epigastric mass or a known AAA may signal rupture into the retroperitoneum or leakage within the aneurysm wall
- This could lead to rapid expansion or imminent rupture.
- Peripheral embolization to the lower extremities (common in popliteal artery aneurysms) is rare with AAAs.
- Rarely in larger or unstable aneurysms, disseminated intravascular coagulopathy may develop.
Physical Examination
- The physical examination may miss a substantial number of asymptomatic AAAs
- The abdominal aorta should be checked during regular physical examinations because it is easy to do and may detect a life-threatening aneurysm.
- The sensitivity of physical examination increases with the size of the aneurysm:
- 29-61% for AAAs 3.0-3.9 cm in diameter
- 76-82% for those AAAs 5.0 cm or larger
- Generally, it is easier to detect a pulsatile mass in thin patients and those who do not have tense abdomens.
- Contrary to popular belief, gentle palpation of AAAs is safe, and does not precipitate rupture.
Differential Diagnosis
- Acute Abdominal Pain
- Acute Cholecystitis
- Perpforated peptic ulcer
- Diverticulitis
- Nephrolithiasis
Conditions Associated with AAAs
- Atherosclerosis
- Cystic medial necrosis
- Vasculitis
- Infectious diseases
- Congenital
- Trauma
Contrast CT
- Provides detailed anatomic information and is valuable in planning AAA repair
- The disadvantages include:
- Nephrotoxicity
- Cost
- Exposure to radiation
- Suboptimal visualization of the origins of the aortic branch vessels
- Occasionally, inaccurate localizing of the aneurysmal neck
Magnetic Resonance Angiography (MRA)
- Does not require nephrotoxic contrast
- Less accurate than thin-slice CT
- Costly, and is not as readily available as contrast CT and ultrasonography
Echocardiography or Ultrasound
- Ultrasonography has a sensitivity close to 100%
- Well accepted by patients
- The preferred method for detecting and following the progression of AAAs
- Able to show the dimensions of the abdominal aorta and other relevant findings:
- Mural thrombus
- Iliac artery aneurysms
- Patients should fast before examination to optimize image quality.
Contrast Aortography
- Performed before surgery in patients suspected of having the following:
- Suprapenal or juxtarenal aneurysms
- Renovascular hypertension
- Ischemic nephropathy
- Mesenteric ischemia
- Associated iliofemoral arterial occlusive disease
- Should not be used to assess the size of an AAA because the common presence of mural thrombus often leads to diameter underestimation
Treatment
Acute Pharmacotherapies
- Antimetalloproteases such as doxycycline and roxithromycin may halt aneurysm expansion
- Similarly, non-steriod anti inflammatory drugs have shown to be beneficial in small studies
- Beta blockers have numerous benefits in patients with cardiovascular disease
- Reduce aortic complications in patients with Marfan syndrome
- Slow progression of AAAs in hypertensive patients
- In the absence of other indications for beta blockers, the evidence is insufficient to recommend using them routinely for the sole purpose of slowing atherosclerotic aneurysm growth
Surgery and Device Based Therapy
Indications for Surgery
The treatment options for asymptomatic AAA are immediate repair, surveillance with a view to eventual repair, and conservative. There are currently two modes of repair available for an AAA: open aneurysm repair (OR), and endovascular aneurysm repair (EVAR).
- Conservative treatment is indicated in patients where repair carries a high risk of mortality and also in patients where repair is unlikely to improve life expectancy. The two mainstays of the conservative treatment are smoking cessation and blood pressure control.
- Surveillance is indicated in small aneurysms, where the risk of repair exceeds the risk of rupture. As an AAA grows in diameter the risk of rupture increases. Although some controversy exists around the world, most vascular surgeons would not consider repair until the aneurysm reached a diameter of 5cm. 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 comorbitities that increase operative risk or decrease life expectancy.
- Open repair (operation) is indicated in young patients as an elective procedure, or in growing or large, symptomatic or ruptured aneurysms. Open repair has been the mainstay of intervention from the 1950's until recently.
- Endovascular repair first became practical in the 1990's 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 AAA's, depending on the morphology of the aneurysm. The main advantage over open repair is that the peri-operative period has less impact on the patient (less time in intensive care, less time in hospital overall, 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 doesn't offer any overall survival benefit.[20] Regarding unruptured aneurysms, EVAR is associated with lower operative mortality than open repair but unknown long-term mortality[21]
Pre-Operative Assessment
- The ADAM trial suggested that the "biological age," as reflected by the condition of the vital organs such as the lungs, kidneys, heart was more important than the chronological age as a determinant of operative outcome. ADAMref4
- Patients with poor renal and pulmonary function have worse operative outcomes
- Chronic obstructive pulmonary disease
- Elevated creatinine concentrations
- Electrocardiographic evidence of ischemia
- Aortic factors implicated in postoperative morbidity and mortality include:
- Extensive atheromatous disease
- Mural calcification
- Thrombosis
- Juxtarenal extension of aneurysm
- Inflammatory aortic aneurysms
- The increased risk resulted from:
- Longer suprapenal clamping time
- Need for complex dissection
- Increased hemodynamic stresses
Pathological Findings
 Dissecting Aneurysm: Gross very good example dissected channel has been opened |
 Dissecting Aneurysm: Gross external view good appearance from adventitia |
 Dissecting Aneurysm: Gross opened false channel |
 Dissecting Aneurysm: Gross good example dissection beginning at third portion aortic arch |
 Dissecting Aneurysm: Gross cross sections showing thrombus in false lumen true lumen has been opened longitudinally |
 Dissecting Aneurysm: Gross shows origin just above aortic valve false channel shown in descending thoracic aorta (very good example) |
 Atherosclerotic Aneurysm: Gross, a good example of typical abdominal aorta aneurysm with mural thrombus |
 Dissecting Aneurysm: Gross, a very good example of dissection beginning just above aortic ring |
 Atherosclerotic Aneurysm: Gross, (rather) good example of abdominal aortic aneurysm |
 Dissecting Aneurysm: Gross, an excellent example, starting just above the aortic valve with reflection of aorta to show the dissection tract and some thrombus |
 Dissecting Aneurysm: Gross shows dilated aorta with extensive atherosclerosis dissection is seen, a small abdominal aorta atherosclerotic aneurysm is present good for association of dilation with dissection |
 Dissecting Aneurysm: Gross arrow points to start of dissection in first portion aortic arch good but not the best example shows dilation |
 Dissecting Aneurysm: Gross, very good to show start of dissection above aortic valve and blood in false channel |
 Dissecting Aneurysm: Gross, heart with root of aorta to show hemorrhage into pericardium (a very good example) |
 Dissecting Aneurysm: Gross, of heart and aorta with dissection and large false channel (a good example) |
 Dissecting Aneurysm: Gross cross section of aorta with two channels (a good example) |
 Atherosclerotic Aneurysm: Gross, a nice view of cross section of abdominal aorta aneurysm |
 Dissecting Aneurysm: Gross good example of typical angular tear above aortic valve |
 Dissecting Aneurysm: Gross good example angular tear above aortic valve |
 Atherosclerotic Aneurysm: Gross, external natural color very good example of an atherosclerotic thoracic aorta aneurysm with focal rupture |
 Atherosclerotic Aneurysm: Gross, excellent color, opened thoracic segment of aorta with two saccular atherosclerotic ruptured aneurysms |
 Atherosclerotic Aneurysm: Gross, an excellent example, natural color, external view of typical thoracic aortic aneurysms |
 Atherosclerotic Aneurysm: Gross unopened lesion natural color |
 Dissecting Aneurysm: Gross dissection first portion of arch fixed specimen (a good example) |
 Dissecting Aneurysm: Gross, rather well shown dissection in first portion of the aortic arch |
 Dissecting Aneurysm: Gross, rather well shown dissection in first portion of the aortic arch |
 Dissecting Aneurysm: Gross, an excellent example of type I lesion |
 Dissecting Aneurysm: Gross, external view, an excellent example |
 Dissecting Aneurysm: Gross, Type I shows false channel |
 Dissecting Aneurysm: Gross, opened to show false channel (good example) |
 Atherosclerotic Aneurysm: Gross, very good example of ruptured thoracic segment |
 Dissecting Aneurysm: Gross, coagulum of blood in false channel |
 Dissecting Aneurysm: Gross, aortic valve area dissection (well shown, typical lesion) |
 Abdominal Aneurysm Ruptured: Gross (good example) opened kidneys in marked place, atherosclerosis in lower thoracic aorta |
 Abdominal Aneurysm: Gross, (very good example) opened lesion with mural thrombus |
 Dissecting Aneurysm: Gross, large tear in first portion of aortic arch, annuloaortic ectasis |
 Dissecting Aneurysm: Gross, external view of heart and first portion of aortic arch, annuloaortic ectasia, hemorrhage beneath adventitia is evidence of dissection |
 Atherosclerotic Aneurysm Infected: Gross, infected abdominal aneurysm at superior suture line with rupture into duodenum |
 Atherosclerotic Aneurysm: Gross, cross sections of repaired aneurysm showing Dacron graft and old mural thrombus. A nice example of fibrin layer in graft |
 Ruptured Syphilitic Aneurysm |
 Dissecting Aneurysm in a patient with Marfan's syndrome |
 Traumatic Aneurysm |
 Kidney: Arteriosclerosis: Gross aorta with well shown renal artery containing large plaque and kidney with multiple cortical scars and atrophy also abdominal aorta aneurysm with mural thrombus (excellent example for renovascular hypertension) |
 Dissecting Aneurysm: Gross, fixed tissue, descending thoracic segment dissection opened to show the false channel. The true surface is also visible |
 Aneurysm: Gross, ruptured thoracic aorta aneurysm, in situ lower thoracic portion (probably due to atherosclerosis) |
 Abdominal Aneurysm Graft Repair: Gross, natural color, close-up view, an excellent example of Dacron graft that has been in place for years with pseudointima and atherosclerosis |
 Dacron Graft: Gross, close-up Dacron graft to repair aneurysm. Aorta completely covered with a calcified and ulcerated plaque with small mural thrombi (an excellent depiction of proximal suture line) |
 Dissecting Aneurysm: Gross natural color descending aorta opened into false channel |
 Abdominal Aneurysm: Gross, natural color, unopened specimen with about a six centimeter aneurysm between renals and bifurcation (a very good example of opened aneurysm) |
 Abdominal Aneurysm: Gross, natural color, an opened aneurysm showing quite well laminated thrombus |
 Atherosclerosis with Mural Thrombi: Gross, natural color, a nice photo of descending thoracic aorta with extensive ulcerated plaques and mural thrombi in distal portion. The case also has an abdominal aneurysm |
 Pseudoaneurysm Ruptured Into Duodenum: Gross natural color aorta and duodenum with arrow pointing to rupture point of aortobifemoral bypass pseudoaneurysm rupture and another in duodenum a very good demonstration of this very well known complication of aortic prostheses |
 Abdominal Aneurysm: Gross, natural color, large aneurysm opened showing sessile calcified plaques with no mural thrombus. Lesion extends from renal arteries to the bifurcation (the same lesion seen externally with focus of rupture) |
 Abdominal Aneurysm Ruptured: Gross, natural color, external view with large area of apparent rupture. Aorta is opened to show this aneurysm) |
Abdominal Aneurysm: Gross, natural color, unopened large and quite typical aneurysm extending from below renal arteries to bifurcation |
 Abdominal Aneurysm: Gross, natural color, opened aneurysm with well shown and typical laminated thrombus (external view) |
 Aortobifemoral Prosthesis: Gross, natural color, nice dissection showing Dacron prosthesis replacing abdominal segment of aorta with portion of atherosclerotic aneurysm with renal arteries and kidneys |
 Aortobifemoral Prosthesis: Gross natural color close-up view of nicely dissected prosthesis extending from below renals to common iliac arteries portion of atherosclerotic aneurysm behind prosthesis |
 Dissecting Aneurysm: Gross natural color close-up view of aortic valve and proximal aortic arch with ruptured intima rather good illustration of this lesion |
 Syphilitic Aneurysm: Gross natural color rather a close-up view and outstanding photo of aneurysm ruptured into the left main stem bronchus |
 Syphilitic Aneurysm: Gross natural color typical tree barking in aorta aneurysm opening is seen in which is a thrombus aneurysm ruptured into left main stem bronchus (shown very well) |
 Dissecting Aneurysm Chronic: Gross natural color first portion of aortic arch with intimal rent well shown with healed margins and view into false channel that shows a surface looking like atherosclerosis which is known to develop in a chronic dissection |
 Dissecting Aneurysm Chronic: Gross, natural color, closer view of the previous one (a very good example) |
Videos on Abdominal Aortic Aneurysm
References
- ↑ Livesay JJ et al. Milestones in Treatment of Aortic Aneurysm. Tex Heart Inst J 2005; 32: 130–134. PMCID 1163455
- ↑ Famous Patients, Famous Operations, 2002 - Part 3: The Case of the Scientist with a Pulsating Mass from Medscape Surgery
- ↑ 3.0 3.1 3.2 3.3 3.4 Treska V. et al.:Aneuryzma břišní aorty, Prague, 1999, ISBN 80-7169-724-9
- ↑ 4.0 4.1 4.2 4.3 4.4 med/3443 at eMedicine
- ↑ 5.0 5.1 Lindholt JS, Juul S, Fasting H, Henneberg EW. Screening for abdominal aortic aneurysms: single centre randomised controlled trial. BMJ 2005; 330: 750. PMCID: 555873
- ↑ Dahnert W. Radiology Review Manual, 5th edition. Lippincott, Williams and Wilkins 2003
- ↑ Rakita, D. et al Spectrum of CT Findings in Rupture and Impending Rupture of Abdominal Aortic Aneurysms, Radiographics 2007;27:497-507
- ↑ U.S. Preventive Services Task Force (2005). "Screening for abdominal aortic aneurysm: recommendation statement". Ann. Intern. Med. 142 (3): 198-202. PMID 15684208.
- ↑ Fleming C, Whitlock EP, Beil TL, Lederle FA (2005). "Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force". Ann. Intern. Med. 142 (3): 203-11. PMID 15684209.ACP Journal Club
- ↑ Cinà CS, Devereaux PJ (2005). "Review: population-based screening for abdominal aortic aneurysm reduces cause-specific mortality in older men". ACP J. Club 143 (1): 11. PMID 15989299.
- ↑ Society for Vascular Surgery
- ↑ 12.0 12.1 Ashton HA, Buxton MJ, Day NE, et al (2002). "The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial". Lancet 360 (9345): 1531-9. PMID 12443589. ACP Journal Club
- ↑ Cina CS (2003). "Screening for abdominal aortic aneurysm reduced death from AAA in older men". ACP J. Club 138 (3): 66. PMID 12725621.
- ↑ Kim LG, P Scott RA, Ashton HA, Thompson SG (2007). "A sustained mortality benefit from screening for abdominal aortic aneurysm". Ann. Intern. Med. 146 (10): 699-706. PMID 17502630.
- ↑ Multicentre Aneurysm Screening Study Group (2002). "Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomized controlled trial". BMJ 325 (7373): 1135. PMID 12433761. ACP Journal Club
- ↑ Lindholt JS, Juul S, Fasting H, Henneberg EW (2005). "Screening for abdominal aortic aneurysms: single centre randomised controlled trial". BMJ 330 (7494): 750. doi:10.1136/bmj.38369.620162.82. PMID 15757960. ACP Journal Club
- ↑ Ashton HA, Gao L, Kim LG, Druce PS, Thompson SG, Scott RA (2007). "Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms". The British journal of surgery 94 (6): 696-701. doi:10.1002/bjs.5780. PMID 17514666.
- ↑ Clifton, MA: Familial abdominal aortic aneurysms. Br. J. Surg., 64, 1977, p. 765-766
- ↑ O'Connor RE: Aneurysm, Abdominal, on emedicine, accessed June 23, 2006.
- ↑ Rutherford RB. Randomized EVAR Trials and Advent of Level I Evidence: A Paradigm Shift in Management of Large Abdominal Aortic Aneurysms? Semin Vasc Surg 2006; 19:69-74. PMID 16782510
- ↑ Lederle FA, Kane RL, MacDonald R, Wilt TJ (2007). "Systematic review: repair of unruptured abdominal aortic aneurysm". Ann. Intern. Med. 146 (10): 735-41. PMID 17502634.
Acknowledgements
The content on this page was first contributed by: C. Michael Gibson M.S., M.D.
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
