CASE REPORT

SUSPECT OF RUPTURE
ABDOMINAL AORTIC ANEURYSM

AORTIC DISSECTION

Anatasia Agatha Yull XC065172011

Supervisor
Dr. dr. Idar Mappangara, Sp.PD, Sp.JP(K), FIHA
PATIENT IDENTITY

Name : Mr. A. G
Age : 68 years old
Address : Makassar
Medical Record : 853546
Date of admission : August 24, 2018
HISTORY TAKING
Chief complaint : abdominal pain
Present illness story
 Patient complaints for having lower abdominal pain (stabbing pain) that radiates to the
back since two days ago. The pain felt coming back and forth.
 A week before, he was riding a motorcycle and was bumped around the abdominal
region thus making the pain arose. He was rushed to RS Ibnu Sina and he got referred
to PJT RSWS for further treatment
 nausea (+), vomiting(-), cold sweat and fever(-)
HISTORY TAKING

Past Illness History

 The patient was hospitalized at RS Ibnu Sina in 2015 for the same complaint
 History of hypertension since 10 years ago, uncontrolled medication
 History of smoking for 30 years, has stopped for almost 10 years to date
 No history of family history with heart disease
 No history of diabetes mellitus
 No history of alcohol consumption
 No history of surgery
PHYSICAL EXAMINATION

 General status
• Mild illness/compos mentis/normal weight
• Weight : 60 kg
• Height : 170 cm
• BMI : 20,8 kg/m2
 Vital sign
• Blood pressure : 148/75 mmHg
• Heart rate : 57 bpm
• Respiratory rate : 24 tpm
• Temperature : 36,5 ˚c

 Pain scale : 4 NRS

PHYSICAL EXAMINATION

 Head and neck

Eyes : anemic (-) icteric (-)
Neck : JVP R+2 cmH2O , limphadenopathy (-)

 Thorax
1. Lung
Inspection : symmetry left and right
Palpation : mass (-) , no tenderness, normal vocal fremitus
Percussion : resonance
Auscultation : vesicular, rhonci -/-, wheezing-/-
PHYSICAL EXAMINATION

2. Cor
Inspection : apical impulse not visible
Palpation : apical impluse is not palpable ,thrill (-)
Percussion :
- upper border 2nd ICS sinistra
- right border 5th ICS linea parasternalis dextra
- left border 6th ICS linea axillaris anterior sinistra
Auscultation :heart sound I/II regular.
PHYSICAL EXAMINATION

 Abdomen
Inspection : flat
Palpation :
- inguinal sinistra region with (superficial) palpation pain.
- liver and spleen is not palpable
Percussion : tympani
Auscultation :
- no bruits sound
- peristaltic normal

 Extremities
No edema
LABORATORY FINDINGS
No Test Result Normal value Unit
HEMATOLOGY
Routine Hematology
1 WBC 12,24 4,00-10,0 10^3/ul
2 RBC 2,80 4,00-6,00 10^6/ul
3 HGB 8,5 12,0-16,0 gr/dl
4 HCT 23,2 37,0-48,0 %
5 MCV 82,9 80,0-97,0 fL
6 MCH 30,4 26,5-33,5 pg
7 MCHC 36,6 31,5-35,0 gr/dl
8 PLT 199 150-400 10^3/ul
Coagulation
1 PT 10,5 10-14 Second
2 INR 0,99 --
3 APTT 30,0 22,0-30,0 Second
LABORATORY FINDINGS
No Test Result Normal value Unit
Blood Chemistry
1 GDS 127 140 Mg/dl
2 D Dimer 2,65 < 0,5 ug/L
Kidney Function
1 Ureum 63 10-50 Mg/dl
2 Creatinine 2,42 L (<1,3); P( <1,1) Mg/dl
Liver Function
1 SGOT 11 <38 U/L
2 SGPT 8 <41 U/L
LABORATORY FINDINGS
No Test Result Normal value Unit
IMUNOSEROLOGY
HBsAg (ELISA) 0,01 / Non < 0,13 COI
1
Reactive
Anti HCV (ELISA) 0,15/ Non < 1,00 COI
2
Reactive
ELEKTROLIT
1 Natrium 141 136-145 Mmol/l
2 Kalium 4,8 3,5-5,1 Mmol/l
3 Klorida 108 97-111 Mmol/l
ELECTROCARDIOGRAM
ELECTROCARDIOGRAM
Rithm : Sinus rhythm
Heart rate : 72 bpm
Regularity : Regular
Axis : normoaxis 45 degree
P Wave : Normal 0,08 second
PR interval : Normal 0,18 second
QRS complex : Normal 0,08 second
Segmen ST : isoelectric
T Wave : inverted T wave in Lead V1-V5 and in Lead II, III, aVf
Conclusions :

Sinus rhythm, HR 72 bpm regular, normoaxis, anterior et inferior ischemic

 THORAX XRAY

 Cardiomegaly with
dilatatio, elongatio
et atherosclerosis
aortae
ECHOCARDIOGRAPHY

 Systolic function of right and left ventricle

are normal, EF 58 %
 Concentric left ventricle hypertrophy
 Mild aorta regurgitation
 Dyastolic dysfunction mild degree
MSCTA (27/8/2018)
 Fusiform infrarenal aortic abdominalis
aneurysm until bifurcatio with thrombus
 Atherosclerosis aortic abdominal
 Atherosclerosis a.iliaca communis
bilateral, a.iliaca ext et int bilateral,
a.femoralis comm bilateral, a.fem sup et
prof bilateral, a.popliteal bilateral, a.tibialis
anterior bilateral and proximal a.tibialis
posterior sinistra
 Retroperitoneal mass sugestion of
m.Psoas major sinistra
 Renal cyst bilateral
 Spondylosis lumbalis
DIAGNOSIS

 Suspect of rupture aortic abdominal

aneurysm
 Aortic dissection
TREATMENT
 Bisoprolol 5mg/24hr/oral
 Captopril 25mg/8hr/oral
 Atorvastatin 40mg/24hr/oral
Planning
 Management of aneurysm: surgical
interventions
discussion.
Anatomy of the Aorta
What is an Abdominal Aortic
Aneurysm (or AAA)?

• An Abdominal Aortic Aneurysm (AAA) is a permanent

localized dilatation of the abdominal aorta.

• The disorder is conventinally diagnosed if the aortic

diameter is 30 mm or more

• Or increase in size of vessel 1 and half times normal

diameter
Patophysiology

Pathological chanes in the aortic wall:

 Inflammatory process

 Causing breakdown of elastic elements

 Decrease tensile strength

 Leading to expansion
Patophysiology

Atherosclerosis
Degeneration and weakening of
tunica media artery
Aging

Turbulance flows in bifurcatio region

Genetic

AAA
Pathophysyiology of a AAA –
aneurysm growth

AAA growth:

 Expansion tends to be highly variable

AAA growth accelerates with the diameter of the AAA
Aneurysm growth is influenced by risk factors
R i s k F a c t o r s
Male

Atherosclerosis
Smoking
History

Risk
Factors

Increasing Hypertension
Age

Family
History
Types of AAA

Morphological Classification:

• True aneurysm
- Fusiform aneurysms

- Saccular aneurysms
•Pseudo-aneurysm
Type of Aortic Abdominal Aneurysm:
I) Infrarenalis;
II) II) Juxtarenalis;
III) III) Pararenalis;
IV) IV) Suprarenalis
How to Diagnose AAA
Atypical abdominal or back pain may be present

Systematic palpation of the abdomen during cardiovascular examination

may detect a pulsatile abdominal mass, but its sensitivity is
poor.

Acute abdominal pain and shock are usually present in the

case of ruptured AAA, sometimes preceded by a less intense abdominal
pain for contained rupture.

Abdomen physical examination:

Inspection : (-)
Auscultation : bruits
Palpation : pulsatile mass
Percussion : percussion pain (+)
 Auxiliary Examinations
Ultrasonography
Screening examination to follow the progression of the aneurysm,
usually can be done with aneurysm <5cm
Auxiliary Examination
CT Scan

For aneurysm size measurement

 Angiography Aorta (Aortography)

Considered the ‘gold standard’ in the past,

aortography enabled optimal imaging of the
length of the aorto-iliac lesion, the collateral or
variant anatomy, the location and severity of
occlusive disease, and the associated
aneurysms in the visceral or iliac arteries. Its
limitations are high radiation dose, contrast
load, and its invasive nature. Also,
this technique does not provide information
about thrombus or the aneurysmal sac, and
may misjudge the aortic diameter.
 Risk of Rupture

Very low in aneurysms less than 4.0 cm in diameter.

5 percent for those 4.0 to 4.9 cm in diameter.

25 percent for those 5.0 to 5.9 cm in diameter.

35 percent for those 6.0 to 6.9 cm in diameter.

75 percent for those 7.0 cm in diameter.

Management of AAA - Concervatives

1. Beta Blockers

2. ACE Inhibitors
Management of AAA – Surgical Intervention

Elective repair is considered for aneurysms that are:

- Bigger than 5.5cm

- Increasing by >0.5cm in 6months

- Symptomatic
Management of AAA – Surgical Intervention

1. Open Repair
- Transperitoneal Approach
- Retroperitoneal Approach
- Minimal Incision Aortic Surgery

2. Endovascular Aortic Aneurysm Repair (EVAR)

Minimal Incision Aortic Surgery
Transperitoneal Approach
Retroperitoneal Approach
Endovascular Aortic Aneurysm Repair (EVAR)
Prognosis

Mortality rate of the patients with abdminal aortic aneurysm bigger

than 5cm is three times bigger
Aorta Dissection

Aortic dissection is defined as disruption

of the medial layer provoked
by intramural bleeding, resulting in
separation of the aortic wall layers
and subsequent formation of a TL and an
FL with or without communication
 Patophysiology of AD

Trauma to endothelium in the intima layer  endolthelial injury  flowing blood

through into the diseased media,  creating False lumen, and leaving the original
(True lumen), and (Intimal flap) in between.
Classification of AD
 Risk Factors AD
Most common RF

Peak incidence M:F =2-5:1

in 60-70s

Found in 7-
14% of all
Most common in
dissection
3rd trimester

Iatrogenic: 5% of all cases, Cardiac cath,

AVR. Trauma at aortic isthmus
Clincial Manifestation
 Main Complication of AD
•30 % get ischemic complications

•In type I mortality due to complications increases 1% per hour

•Etiology

Dynamic obstruction
Occlusion of true lumen by false lumen

Static obstruction
Compression, disruption, thrombosis
Pawan et al, Ther Adv Cardiovasc Dis, 2008
Main Goals of Medical Management

• Control pain
• Control heart rate
• Control blood pressure
Management of AD - Concervatives

1. Beta-Blockers
2. Calcium Channel Blockers
3. Angiotensin Receptor Blockers
 Management of AD - Surgical
1. Tree branch arch aortic replacement

2. Frozen Elephant Trunk

 Management of AD - Surgical

3. Thoracic Endovascular Aortic Repair

THANK YOU