ABDOMINAL AORTIC ANEURYSMS

Part one of Review Handbook on Vascular Surgery. This is meant for revision and should not be
used as initial study. Prepared by Dr Dale Maharaj FRCS FICS FICA

Definition
Aneurysm: a focal dilatation of a blood vessel 1.5 to 2 times the diameter of the
native vessel. (The normal diameter of the infrarenal aorta is about 2 cm. This vessel is
generally considered aneurysmal above 3 cm

Aneurysm wall can be saccular or fusiform.

Pseudoaneurysm: wall is not made up of vascular
wall. Can occur following penetrating trauma or at
anastomotic site.

Incidence
AAA is most commonly diagnosed in the 7th decade of life
Men outnumber women by 4 to 1
Prevalence estimated at 2-5 percent in men over age of 60
Incidence is approximately 30-60 per 1000 of population and increasing
1 in 5 patients with PAOD
Etiology

Atherosclerotic Degeneration (90%)

Congenital- Turner syndrome, Menke syndrome, idiopathic

Infection- Salmonella, Streptococcus, Staphylococcus, Syphilis

Arteritis

Mechanical- traumatic, anastomotic

Inflammatory

Connective tissue abnormalities- Marfans, Ehlers-Danlos syndromes

Risk Factors
Increased risks
Smoking
Family history
Older age
Coronary artery disease
High cholesterol
COPD
Height

Decreased Risks
DVT
Diabetes Mellitus
Black race
Female gender

Clinical Presentation

70-75 percent are asymptomatic at presentation

Abdominal pain
Back/lumbar pain
Beating in abdomen
Pulsatile & EXPANSILE mass
Other aneurysms eg popliteal, femoral

Symptoms typically develop with rupture or expansion, but may develop

from pressure on adjacent structures, distal embolization or less commonly
thrombosis

Rupture- severe abdominal pain, pulsatile abdominal mass and

hypotension
Diagnostic Studies

Plain abdominal radiographs: egg Shell appearance due to Aim:

calcification
1.Confirm dx
2.Renal involvement ie

Ultrasound: to confirm diagnosis & determine the size and infra/suprarenal

3.Iliac involvement
extent

Dynamic contrast-enhanced CT scan: test of choice

MRI
Aortography: will underestimate size of aneurysm

Supportive studies (investigations in preparation for surgery)

Blood work up: Hb, Renal Function, Blood Glucose levels, Vasculopath
Full vessel work up

Group and Crossmatch 4-6 Units of Blood

Preoperative Cardiac Evaluation: ECG, ECHO

Carotid Duplex Assessment: risk of stroke

Indications for surgery

AAA > 5 cm diameter
Ruptured AAA
Rapid increase in size
Symptomatic AAA
5cm is NOT pulled out of a hat

Rupture caries a high mortality

(80%)

Risk of rupture dependent primarily

on size

< 4 cm = 0% per year

4 5 cm = 3% per year
> 5 cm = 5 50% per year

including coronaries and

carotids

Surgery
1. Operative approach
o Transperitoneal approach (laparotomy)
o Retroperitoneal approach
2. Control the proximal & distal aorta/iliacs
3. Inlay prosthetic graft
4. Cover graft with aortic wall
Endovascular aortic grafting

decreased blood loss

minimization of cardiac, pulmonary and abdominal complications

decreased length of stay

Perioperative Complications of Elective AAA Repair

Hemorrhage

Aortic declamping shock

Renal failure esp with suprarenal clamping

Ischemic colitis

Prolonged ileus

Ureteral injuries

Distal embolization: trash foot

Paraplegia

MI

Stroke

Pelvic/Buttock ischemia
Screening

Selective screening may be cost-effective

Family history of aneurysms

55-80 years old with peripheral vascular disease

Known extremity aneurysm

Best method is ultrasound

Late Complications
Graft infection- common in 1st year
Anastomotic aneurysm- 1-3%
Aortoenteric fistula
Graft limb occlusion

CT scan (T=thrombus, * =lumen)

Proximal and distal control with inlaying of graft

Retroperit

oneal approach