Abdominal Aortic Aneurysm

Key Features

Essentials of Diagnosis

• Most aortic aneurysms are asymptomatic until rupture, which is catastrophic

• Aneurysms measuring 5 cm are palpable in 80% of patients

• Back or abdominal pain with aneurysmal tenderness may precede rupture

• Hypotension

• Excruciating abdominal pain that radiates to the back

General Considerations

• The aorta of a healthy young man measures approximately 2 cm

• An aneurysm is considered present when the aortic diameter exceeds 3 cm

• Aneurysms rarely cause rupture until diameter exceeds 5 cm

• 90% of abdominal atherosclerotic aneurysms originate below the renal arteries

• Aortic bifurcation is usually involved

• Common iliac arteries are often involved

Demographics

• Found in 2% of men over age 55

• Male to female ratio is 4:1

Clinical Findings

Symptoms and Signs

• Most asymptomatic aneurysms are discovered as incidental findings on ultrasound or CT imaging

• Symptomatic aneurysms

• Mild to severe midabdominal pain due to aneurysmal expansion often radiates to lower back

• Pain may be constant or intermittent, exacerbated by even gentle pressure on aneurysm sack, and may
also accompany inflammatory aneurysms
• Inflammatory aneurysms have an inflammatory peel, similar to the inflammation seen with
retroperitoneal fibrosis, surrounds the aneurysm and encases adjacent retroperitoneal structures, such
as the duodenum and, occasionally, the ureters

• Ruptured aneurysms

• Severe pain

• Palpable abdominal mass

• Hypotension

• Free rupture into the peritoneal cavity is lethal

• Most aneurysms have a thick layer of thrombus lining the aneursymal sac;

• Embolization to lower extremities is rarely seen

Differential Diagnosis

Diagnosis

Laboratory Tests

• Hematocrit will be normal, since there has been no opportunity for hemodilution

• Patients with aneurysms may also have the cardiopulmonary diseases of elderly male smokers, which
include

• Coronary artery disease

• Carotid disease

• Renal impairment

• Emphysema

• Preoperative testing may indicate the presence of these comorbid conditions

Imaging Studies

• Abdominal ultrasonography

• Diagnostic study of choice for initial screening

• Useful in screening 65- to 74-year-old men, but not women, who have a history of smoking

• Repeated screening does not appear to be needed

• Abdominal or back radiographs: curvilinear calcifications outlining portions of aneurysm wall may be
seen in approximately 75% of patients

• CT scans

• Provide a more reliable assessment of aneurysm diameter

• Should be done when the aneurysm nears the diameter threshold (5.5 cm) for treatment

• Contrast-enhanced CT scans

• Show the arteries above and below the aneurysm

• Visualization of this vasculature is essential for planning repair

Treatment

Emergency Repair

• If the bleeding is confined to the retroperitoneum, blood loss may be arrested long enough for the
patient to undergo urgent operation

• Endovascular repair is available for urgent aneurysm repair in most major vascular centers, with the
results offering some improvement over open repair for these critically ill patients

Elective Repair

• Generally indicated for aortic aneurysms ≥ 5.5 cm in diameter or aneurysms that have undergone rapid
expansion (> .5 cm in 6 months)

Surgery

• Not indicated when inflammatory aneurysm is present unless retroperitoneal structures, such as the
ureter, are compressed

• Interestingly, the inflammation that encases an inflammatory aneurysm recedes after either
endovascular or open surgical aneurysmal repair

• Open surgical aneurysm repair

• Graft is sutured to the non-dilated vessels above and below the aneurysm

• This involves an abdominal incision, extensive dissection, and interruption of aortic blood flow

• Mortality rate is low (2–5%) when the procedure is performed in good risk patients in experienced
centers

• Older, sicker patients may not tolerate cardiopulmonary stresses of the surgery
Endovascular Repair

• Stent-graft is used to line the aorta and exclude the aneurysm

• Anatomic requirements to securely achieve aneurysm exclusion vary according to performance

characteristics of the specific stent-graft device

• Stent must be able to seal securely against the wall of the aorta above and below the aneurysm,
thereby excluding blood from flowing into the aneurysm sac

• Long-term survival is equivalent between the two techniques

• Patients who undergo endovascular repair require more repeat interventions and need to be
monitored postoperatively since there is a 10–15% incidence of continued aneurysm growth post
endovascular repair

Outcome

Follow-Up

• Once an aneurysm is identified, routine follow-up with ultrasound determines size and growth rate

• The frequency of imaging depends on aneurysm size ranging from every 2 years for small (< 4 cm
aneurysms) to every 6 months for aneurysms at or approaching 5 cm

• At approximately 5 cm, a CT angiography with contrast should be done to more accurately size the
aneurysm and define the anatomy

Complications

• Myocardial infarction

• Routine infrarenal aneurysms

• Respiratory complications are similar to those seen in most major abdominal surgery

• Gastrointestinal hemorrhage

Prognosis

• Open elective surgical resection

• Mortality rate is 1–5%

• Of those who survive surgery, about 60% are alive at 5 years

• Myocardial infarction is leading cause of death

• Endovascular aneurysm repair

• May be less definitive than open surgical repair

• In high-risk patients, endovascular approach reduces perioperative morbidity and mortality

• Prognosis depends on how successfully aneurysm has been excluded from the circulation

• Mortality rates among patients with large aneurysms

• 12% annual risk of rupture in aneurysms ≥ 6 cm in diameter

• 25% annual risk of rupture in aneurysms ≥ 7 cm diameter

When to Refer

• Any patient with a 4 cm aortic aneurysm or larger should be referred for imaging and assessment by a
vascular specialist

• Urgent referrals should be made if the patient complains of pain and gentle palpation of the aneurysm
confirms that it is the source, regardless of aneurysm size

When to Admit

• Signs of aortic rupture

References

De Bruin JL et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N
Engl J Med. 2010 May 20;362(20):18819. [PMID: 20484396]

Jackson RS et al. Comparison of long-term survival after open vs endovascular repair of intact abdominal
aortic aneurysm among Medicare beneficiaries. JAMA. 2012 Apr 18;307(15):16218. [PMID: 22511690]

Kim LG et al. Multicentre Aneurysm Screening Group. A sustained mortality benefit from screening for
abdominal aortic aneurysm. Ann Intern Med. 2007 May 15;146(10):699706. [PMID: 17502630]

Kurosawa K et al. Current status of medical treatment for abdominal aortic aneurysm. Circ J. 2013 Nov
25;77(12):28606. [PMID: 24161907]

Lederle FA et al; Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group.
Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.
JAMA. 2009 Oct 14;302(14):153542. [PMID: 19826022]

Schermerhorn ML et al. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare
population. N Engl J Med. 2008 Jan 31;358(5):46474. [PMID: 18234751]

United Kingdom EVAR Trial Investigators; Greenhalgh RM et al. Endovascular versus open repair of
abdominal aortic aneurysm. N Engl J Med. 2010 May 20;362(20):186371. [PMID: 20382983]
Wallace GA et al. Favorable discharge disposition and survival after successful endovascular repair of
ruptured abdominal aortic aneurysm. J Vasc Surg. 2013 Jun;57(6):1495502. [PMID: 23719035]