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abdominal aortic aneurysm (AAA)

Etiology: - see aortic aneurysm - advanced age, smoking, male sex, atherosclerosis, hypertension & family history most important risk factors - higher diastolic blood pressure associated with increased risk [31] * diabetes mellitus associated with decreased risk [33] Epidemiology: - see aortic aneurysm - growth & rupture rates may be faster in women than men - mean aneurysm diameter at the time of repair smaller in the U.S. than the U.K. - twice as many intact AAAs repaired in U.S. than in the U.K. - AAA-related mortality > 3X as high in the U.K. as in the U.S. [42] Pathology: - degenerative changes in the aortic wall - chronic inflammation - infiltration by lymphocytes & macrophages - destructive remodeling of the extracellular matrix - destruction of elastin & collagen in the media & adventitia by matrix metalloproteinases - depletion of vascular smooth muscle cells with thinning of the media - neovascularization * aortic dissection is a distinct process - most often involves the thoracic aorta - rarely the source of aneurysms isolated to the infrarenal aorta [32] Genetics: - defects in COL3A1 associated with susceptibility Clinical manifestations: 1) most patients are asymptomatic 2) symptoms when they do occur include: a) abdominal discomfort b) back pain c) pain in the legs, groin or chest d) anorexia, nausea/vomiting if the aneurysm compresses the duodenum e) flank, thigh or scrotal pain from compression of the left genitofemoral nerve f) unilateral leg swelling caused by compression of the left iliac vein g) syncope, shock Special laboratory: - 12 lead EKG prior to repair Radiology: 1) abdominal ultrasound (US) -> abdominal aorta US - identify maximum diameter - not for identification of aneurysm rupture - follow-up abdominal ultrasound (unrepaired AAA) - 6 month intervals for AAA 4.4-5.4 cm - 6-12 months for 4.7 cm AAA [2] - 1 year intervals for AAA 3.5-4.4 cm; 4.0-4.4 cm [2] - 2-3 year intervals for AAA < 4.0 cm [2] - 5 year intervals for AAA 2.6-2.9 cm [2] 2) abdominal CT or MRI a) caudal-cephalic extent b) patency of renal arteries c) status of celiac, superior & inferior mesenteric arteries d) extension into the iliac arteries e) non-contast CT useful if renal insufficiency f) aneurysm rupture 3) maximal AAA diameter ~1 cm larger by CT than US [5] - may be due to oblique cut measurements by CT 4) normal abdominal aorta size is 1.4-3.0 cm 5) CT angiography abdomen & pelvis - identify involvement of renal artery & mesenteric arteries [2] - indicated for planning surgical repair [2] - suprarenal & juxtarenal aneurysms most often necessitate open repair [2] - abdominal aorta CT angiogram (Loinc) - MRA abdominal aorta (Loinc) * annual growth of AAA 3.5-5.0 cm (men), 3.5-4.5 cm (women) [48] - median growth rate is 0.17 cm per year - 10% show < 0.05 cm per year - 28% show > 0.25 cm per year - no patient with maximum diameter < 4.25 cm reached threshold for surgical repair within 2 years (5.0 cm women, 5.5 cm men) [48] * heavy calcification is associated with slower growth [51] Complications: 1) sudden death 2) rupture of aneurysm - annual incidence of < 0.5% for aneurysms < 4.0 cm [2] - annual incidence of 0.5-5% for aneurysms 4.0-4.9 cm - annual incidence of 3-15% for aneurysms 5.0-5.9 cm - annual incidence of 10-20% for aneurysms 6.0-6.9 cm - annual incidence of 30-40% for aneurysms 7.0-9.9 cm - annual incidence of 30-50% for aneurysms >= 8.0 cm [2] - incidence of 1% for men, 4% for women for aneurysms 5.0-5.9 cm - incidence of 14% for men, 22% for women for aneurysms > 5.9 cm - abdominal pain, back pain & syncope may herald an AAA rupture [2] - endovascular repair with similar outcomes to open repair] [29] 3) distal embolization (emboli often small) [3] 4) aortic diameter of 2.5-2.9 cm is associated with a) excess risk of hospitalization b) 30% chance of developing AAA [20] 5) aortic diameter >= 3.0 is associated with excess risk of mortality [RR = 2.6) [20] 6) aortoenteric fistula with repair of AAA Management: 1) also see aortic aneurysm - target modifiable risk factors: smoking cessation - presence of intramural thrombus is not an indication for anticoagulation [54] 2) aneurysms < 5.5 cm in diameter (men), < 5.0 cm (women) [1,33] a) may be closely observed b) endovascular repair of aneurysms < 5.5 cm in diameter does not improve mortality [18] 3) surveillance imaging (US) every 12 months for AAA 4.0-4.9 cm to assess progression & need for surgery [43) - assessment of femoral artery & popliteal artery 4) treat hypertension a) ACE inhibitor may reduce risk of rupture (RR=0.82) [12] b) no evidence supports preferential use of beta-blockers [2] 5) no benefit of statins [27] or doxycycline [30] in slowing progression of AAA 6) surgery a) indications 1] aneurysm > 5.5 cm [1,2] in diameter with life expectancy of > 2 years; > 5.0 cm in women [32] 2] aneurysm increasing > 1 cm in diameter in 1 year; > 0.5 cm/year [2] 3] aneurysm rupture - symptomatic patients require urgent repair [33] b) preoperative cardiac stress testing does not reduce perioperative cardiac events or improve outcomes [49] c) procedures 1] open surgery 2] endovascular stent-graft via femoral arteriotomy - lifelong surveillance, including imaging, for patients with AAA endovascular aortic repair with endovascular stent; imaging within 30-days 7 annually thereafter [50] - perioperative mortality may be less with endovascular repair, 1.2% vs 4.8% [14,16,17,32,41] - long-term mortality advantage for endovascular repair may persist in patients >= 85 years of age [14] - no difference in long-term mortality [17,19,23,33,41] - patients treated with endovascular repair require long-term surveillance owing to a small risk of aneurysm sac reperfusion & late rupture [33,41] - late rupture occurs in 5.4% after endovascular repair vs 1.4% after open repair [36] - endovascular repair is associated with lower short-term mortality but more secondary surgical procedures during follow-up [46] - not all patients have anatomy amenable to endovascular repair [33] - involvement of renal artery or mesenteric artery favors open repair - open repair for supra-renal & juxta-renal aneurysms [2] - continuation of dual antiplatelet therapy with endovascular repair if < 6 months after placement of drug-eluting coronary stent [43] - Aneurex & Ancure stent grafts FDA approved Sept 1999 - see Endovascular Aneurysm Repair & DREAM trials 3] anesthesia: - local vs general anesthesia - octogenarians fare better under local anesthesia for elective endovascular aortic aneurysm repair [55] d) complications of surgical repair: - myocardial infarction, renal failure [34] - aortoenteric fistula 7) screening a) one time screening for men age 65-75 who have smoked > 100 cigarettes [2,9,10,15,24,32,47] (USPSTF 2014, 2019) b) selective screening for men aged 65-75 who have never smoked [32,47] (USPSTF) c) evidence is insufficient to assess benefits vs harms of screening for women aged 65-75 years who have ever smoked [32,47] (USPSTF) d) USPSTF recommends against routine screening for women who have never smoked [32,47] (2014) e) screening reduces mortality from AAA in men > 65 years - 352 screenings to save one life [11] f) screening is cost-effective [21] g) screening twice in men with aortic diameters of 25-29 mm at initial screening may also be cost-effective [22] h) no consensus on screening [6,7,9] (2002-2004)

Interactions

disease interactions

Related

endovascular graft (endovascular repair) repair of abdominal aortic aneurysm screening for abdominal aortic aneurysm (AAA)

Specific

ruptured abdominal aortic aneurysm

General

aortic aneurysm

Database Correlations

OMIM correlations MORBIDMAP 120180

References

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