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Overview

An abdominal aortic aneurysm is a localized dilatation of the abdominal aorta, that exceeds the normal diameter of the abdominal aorta by more than 50%. The normal diameter of an aorta depends on the patient's age, sex, height, weight, race, body surface area, and baseline blood pressure. On average, the normal diameter of the infrarenal aorta is 2 cm, and therefore a true AAA measures 3.0 cm or more. 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 the vessel walls.

Causes

Life Threatening Causes

Abdominal aortic aneurysm is a life-threatening condition and must be treated as such irrespective of the underlying cause.

• Abdominal trauma
• Bacteremia
• Gastrointestinal perforation
• Vertebral osteomyelitis

Common Causes

• Abdominal trauma
• Atherosclerosis
• Marfan syndrome

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Abbreviations:

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Characterize the symptoms: ❑ Asymptomatic ❑ Majority of the patients are asymptomatic (Detected incidentally) ❑ Symptomatic but not ruptured ❑ Pain with an indolent onset ❑ Abdominal pain ❑ Back pain ❑ Groin pain (scrotum) ❑ Pulsating sensations in the abdomen ❑ Limb ischemia (suggestive of embolism of thrombus or atherosclerotic debris) ❑ Systemic manifestations(suggestive of primary aortic infection with aneurysm formation or secondary infection of an established AAA) ❑ Fever ❑ Malaise ❑ Symptomatic and ruptured ❑ Severe pain described as severe, sudden, persistent, or constant ❑ Back/flank pain (suggestive of proximal aortic rupture near the renal arteries) ❑ Abdominal/pelvic pain (distal rupture near the iliac bifurcation) ❑ Pain that radiates to the groin or thigh (suggestive of lumbar nerve irritation) ❑ Hypotension ❑ Syncope, fainting (suggestive of hemorrhage) ❑ Symptoms of myocardial infarction (due to acute blood loss) ❑ Chest pain radiating to the lower jaw, neck, right arm, back, and upper abdomen ❑ Anxiety ❑ Palpitation ❑ Sweating ❑ Rapid, weak pulse ❑ Shortness of breath ❑ Rapid breathing ❑ Clammy skin ❑ Symptoms of heart failure (suggestive of arteriovenous fistula as a result of rupture of the aorta into a surrounding venous structure ) ❑ Hematuria (suggestive of aortocaval fistula) ❑ Massive leg swelling and lower extremity cyanosis (suggestive of aortocaval fistula) ❑ Groin pain and hernia (suggestive of aortocaval fistula) ❑ Upper gastrointestinal bleeding (suggestive of aortoduodenal fistula)

Obtain a detailed history: ❑ History to find out the risk factors for development of aneurysm ❑ Hyperlipidemia ❑ Connective tissue disorder ❑ Marfan syndrome ❑ Ehlers-Danlos syndrome ❑ Relapsing polychondritis ❑ Pseudoxanthoma elasticum ❑ Polycystic kidney disease ❑ Loeys-Dietz syndrome ❑ Turner's syndrome ❑ COPD (Emphysema) ❑ Hypertension ❑ History to find out the risk factors for expansion of aneurysm ❑ Cardiac or renal transplant ❑ Stroke ❑ Cardiac disease ❑ History to find out the risk factors for rupture of aneurysm ❑ Female gender ❑ Cardiac or renal transplant ❑ Hypertension ❑ Family history ❑ Abdominal aortic aneurysm ❑ Alpha 1-antitrypsin deficiency ❑ Past Medical History ❑ Diabetes mellitus (Negatively associated with AAA) ❑ Atherosclerosis ❑ Peripheral artery disease ❑ Giant cell arteritis ❑ Hemorrhoids ❑ Esophageal varices ❑ Social History ❑ Smoking History (Strongest risk factor) (smoked at some point in their life) ❑ Alcohol History ❑ Anatomic deformities ❑ Bicuspid aortic valve ❑ Coarctation of the aorta ❑ Infections of the aorta (aortitis)(very rare) ❑ Syphilis ❑ Salmonella ❑ Staphylococcus ❑ Trauma ❑ Arteritis ❑ Cystic medial necrosis

Examine the patient: Vitals ❑ Temperature ❑ Fever ( suggestive of infected aneurysm) ❑ Pulse ❑ Rate ❑ Tachycardia (due to increased blood loss) ❑ Bradycardia (suggestive of shock) ❑ Symmetry ❑ Asymmetric pulses (suggestive of aortic pathology in the chest) ❑ Blood pressure ❑ Hypotension (suggestive of rupture of the aneurysm) ❑ Hypertension (suggestive of expansile aneurysm) ❑ Respiratory rate ❑ Tachypnea (suggestive of shock) Skin ❑ Cyanosis (suggestive of frank shock or rupture of the aneurysm) Neck ❑ Carotid bruits (suggestive of atherosclerosis) ❑ Elevated jugular venous pressure (suggestive of heart failure due to arteriovenous fistula) Abdomen ❑ Abdominal distention (suggestive of hernia due to increased intrabdominal pressure) ❑ Abdominal tenderness ❑ Rebound tenderness ❑ Pulsatile Abdominal mass ❑ Signs of retroperitoneal hematoma ❑ Ecchymosis in the flank (Grey-Turner's sign) ❑ Ecchymosis around the umbilicus (Cullen’s sign) ❑ Discoloration of the scrotum (Bryant’s sign)(suggestive of retroperitoneal hematoma) ❑ Ecchymosis of the proximal thigh (Fox’s sign) Extremities ❑ Peripheral artery aneurysm (eg, femoral, popliteal) ❑ Signs of limbischemia (suggestive of embolism of thrombus or atherosclerotic debris from the aneurysm) ❑ Painful ❑ Pulseless ❑ Pale in color ❑ Perishing cold- Freezing cold feeling, a painful cold temperature. ❑ Paraesthetic feeling such as burning or tingling ❑ Paralysed ❑ Claudication (suggestive of peripheral artery disease)

Consider alternate diagnosis: ❑ Acute cholecystitis ❑ Gastritis and peptic ulcer disease ❑ Gastrointestinal bleeding ❑ Ischemic bowel ❑ Diverticulitis ❑ Nephrolithiasis ❑ Pyelonephritis ❑ Appendicitis ❑ Cholelithiasis ❑ Large bowel obstruction ❑ Small bowel obstruction ❑ Pancreatitis ❑ Musculoskeletal pain ❑ Myocardial infarction ❑ Urinary tract infection in women

❑Symptomatic and unstable ❑ For unstable patient with a known AAA OR ❑ Patients presenting with classic symptoms and signs of rupture ❑ Abdominal/back/flank pain, ❑ Hypotension ❑ Pulsatile mass

Order lab tests: ❑ For patients with acute abdominal complaints ❑ Complete blood count ❑ Electrolytes ❑ Blood urea nitrogen ❑ Creatinine ❑ Additional tests for patients presenting with shock ❑ Liver function tests ❑ Coagulation parameters ❑ Fibrinogen ❑ Fibrin split products ❑ Arterial blood gases ❑ Lactate level ❑ Cardiac enzymes ❑ Toxicology studies ❑ Order Imaging study ❑ Abdominal ultrasound (preferred in asymptomatic patients) ❑ Measure the anteroposterior (AP), longitudinal and transverse dimensions of the aorta ❑ Do a Focused Assessment with Sonography in Trauma (FAST) exam to rule out retroperitoneal hematoma (in hemodynamically unstable patients) ❑ Computed tomography (CT)(used in symptomatic but stable patients) ❑ Differentiates ruptured from nonruptured aneurysm ❑ Can evaluate suprarenal aneurysms ❑ Helps defining the extent of the aneurysm to plan for surgery ❑ Magnetic resonance imaging (MRI) (used in known AAA (unrepaired or post-repair) with contraindications to contrast)

❑ Take this patients to the operating room for immediate management and diagnose intraoperatively ❑Imaging is highly desirable, but is not absolutely required prior to intervention

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Treatment

Shown below is an algorithm summarizing the treatment of Abdominal aortic aneurysm according the the [...] guidelines.