questions 8

Abdominal Aortic Aneurysm

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Topic updated on 09/11/17 10:51am

Overview
 

 
Snapshot
  • AAAA 61-year-old male with a history of CAD and HTN is found to have a pulsatile abdominal mass on palpation. A bruit is heard on ausculation.
Introduction
  • Characterized by ballooning (aneurysmal) dilatation of the aorta
  • Occurs most commonly secondary to atherosclerosis
    • most are abdominal in origin
      • 90% occur below the renal arteries
    • rarely present at or around the aortic arch
  • Risk factors include
    • HTN
    • hypercholesterolemia
    • atherosclerosis
    • family history
    • tobacco
    • male gender
    • increasing age
    • Marfan's syndrome
Presentation
  • Symptoms
    • usually asymptomatic 
      • discovered incidentally on exam or imaging study
    • can present with
      • pulsatile sensation
      • back pain
      • vague epigastric pain
    • ruptured aneurysms present with 
      • hypotension
      • severe, tearing abdominal pain radiating to the back
  • Physical exam
    • pulsatile mass in the abdomin
    • abdominal bruits
    • evidence of lower extremity arterial insufficiency
Imaging
  • Ultrasound 
    • all men age 65+ who have ever smoked should be screened with an ultrasound
    • is diagnostic gold standard
      • < 5 cm => monitor with repeat ultrasounds
      • > 5 cm => surgical repair and further management
    • used to follow AAA over time
  • AXR/KUB
    • may show vascular calcification
  • CT
    • best modality to determine anatomy and size
  • Aortogram
    • for definitive diagnosis
Differential
  • Pancreatitis, pseudocyst, appendicitis, gallbladder disease, aortic dissection
Treatment
  • Nonoperative
    • clinical observation
      • indications
        •  asymptomatic and < 5 cm in size
        • < 6 cm in poor surgical candidate
  • Operative
    • surgical repair  
      • indications
        • large lesions
          • > 5.5 cm in the abdomen 
          • > 6 cm in the thoracic cavity
        • smaller lesions that are rapidly enlarging on follow-up
    • emergent surgery 
      • indications
        • symptomatic lesions
        • ruptured aneurysms
Complications
  • Myocardial infarct
    • is the most common cause of death after elective surgical repair
  • Thrombosis and post-operative emboli
    • can lead to
      • renal failure
      • GI hemorrhage from colonic ischemia 
  • Aortoduodenal fistula
    • can occur s/p surgery and graft placement
    • presents with GI bleed
  • Other complications
    • endograft infection, ischemia of internal organs (including kidney, intestines, and pelvic organs)
    • contrast-induced nephropathy or allergic reaction
    • aortocaval fistula (though rare)
    • gross hematuria 2/2 congestion of weak bladder veins leading to rupture
Prognosis & Prevention
  • Prognosis
    • ranges depending on severity of lesion and timing of diagnosis
      • good to excellent in smaller lesions and when identified early
      • poor if aneurysm leads to dissection and/or rupture
  • Prevention
    • possible if identified early via thorough physical exam and regular primary care visits
    • screening with ultrasound indicated in men ages 65-75 who have ever smoked 


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Qbank (7 Questions)

TAG
(M3.CV.6) A 76-year-old male with a history of hypertension, CAD, and asthma presents to the emergency department with abdominal pain and lightheadedness. He states that his symptoms began suddenly an hour ago leading him to seek care in the ED. Upon questioning, he has a 35-pack-year smoking history and has not seen a primary care physician in over 20 years. His ED vitals are given: T: 36 deg C, HR: 110 bpm, BP: 90/50, RR: 14, SaO2: 97% and the findings shown in Figure A are observed. An EKG is immediately obtained which is demonstrated in Figure B. Concomitantly with gaining IV access and performing volume resuscitation, what diagnostic test should be performed immediately? Topic Review Topic
FIGURES: A   B        

1. Non-contrast chest CT
2. Troponin/CK MB
3. Amylase/Lipase
4. Bedside abdominal ultrasound
5. Chest radiograph

PREFERRED RESPONSE ▶
TAG
(M3.CV.19) A 79-year-old male presents to the Emergency Department with abdominal pain. The patient describes the pain as severe, ripping, and radiating to the back. His history is significant for hypertension, hyperlipidemia, intermittent claudication, and a 60 pack-year history of smoking, and a previously diagnosed aneurysm in his abdomen tracked by ultrasound screening about which the patient was told was stable and not a threat to his health 12 months ago. On exam, the patient's temperature is 98 deg F (36.7 deg C), pulse is 113/min, blood pressure is 84/46 mmHg, respirations are 24/min and oxygen saturation is 99% on room air. The patient is pale and diaphoretic. Which of the following is most appropriate in the evaluation and treatment of this patient? Topic Review Topic

1. Abdominal ultrasound
2. Abdominal CT without contrast
3. Abdominal CT with contrast
4. Abdominal MRI
5. Surgery

PREFERRED RESPONSE ▶
TAG
(M3.CV.23) A 73-year-old female with a history of hypertension, diabetes, and coronary artery disease presents to the emergency department with severe back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. On exam, her vitals are given: T: 37 deg C, HR: 115 bpm, BP: 95/53, RR: 14, SaO2: 97% and the findings shown in Figure A are observed. An abdominal CT with contrast is obtained and is demonstrated in Figure B. A presumptive diagnosis of a ruptured abdominal aortic aneurysm is made. What is the best definitive management for this patient? Topic Review Topic
FIGURES: A   B        

1. Emergent endovascular aneurysm repair
2. Administration of tissue plasminogen activator
3. Volume resuscitation and watchful waiting
4. Administration of tranexamic acid
5. Administer IV blood products

PREFERRED RESPONSE ▶
TAG
(M2.CV.22) On post-operative day 1 following an abdominal aortic aneurysm repair, a 65-year-old patient complains of increasing abdominal pain. On physical exam, there is no rebound tenderness or guarding. The patient has yet to consume food by mouth since his operation and reports no appetite. A STAT CT scan is ordered, which shows intensely edematous haustral folds as shown on the attached image. What is the most likely etiology for this finding on CT scan? Topic Review Topic
FIGURES: A          

1. Adhesions
2. Ischemia
3. Bowel perforation
4. Small bowel obstruction
5. Abscess

PREFERRED RESPONSE ▶
TAG
(M2.CV.29) The United States Preventative Services Task Force (USPSTF) recommends ultrasound screening for abdominal aortic aneurysm (AAA) in asymptomatic patients in which of the following populations? Topic Review Topic

1. Pregnant women
2. Men and women ages 65-75 who have ever smoked
3. Men ages 65-75 who have ever smoked
4. Men ages 65-75 only if >10 pack-year smoking history
5. Ultrasound screening for AAA is not recommended in asymptomatic patients

PREFERRED RESPONSE ▶
TAG
(M2.CV.75) A 65-year-old male with a history of hypertension presents to the emergency with severe back pain. He states that he was straining to pick up a box in the hospital storeroom in which he works when it started. His vitals at the emergency room shortly thereafter are T 98.7, HR 110, BP 90/65, and RR 20. Which of the following is the most likely diagnosis? Topic Review Topic

1. Vertebral compression fracture
2. Muscle strain
3. Herniated disk
4. Ruptured aortic aneurysm
5. Spondylolisthesis

PREFERRED RESPONSE ▶
TAG
(M2.CV.187) A 75-year-old man with a 52-pack-year smoking history and a long history of poorly controlled hypertension presents to general medical clinic for follow up of an incidental finding on abdominal imaging. The patient was admitted several weeks ago with appendicitis and was treated with laproscopic appendectomy without complication. However, on discharge, the medical team brought the following to the patient's attention (Figure A). The patient has no complaints. Vital signs are stable, but on abdominal examination there is a palpable, pulsating mass. What is the cut-off diameter for surgical intervention in this patient's disease? Topic Review Topic
FIGURES: A          

1. >4.0cm
2. >4.5cm
3. >5.0cm
4. >5.5cm
5. >6.0cm

PREFERRED RESPONSE ▶
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