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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Dilatation of the infrarenal aorta (> 3 cm in diameter)

  • Incidence increases with age and more common in men > 65 years old who have smoked

  • Most are asymptomatic until rupture; then 85% of patients die suddenly before reaching the hospital

GENERAL CONSIDERATIONS

  • Up to 4% of men over age 65 have abdominal aortic aneurysm (AAA) by ultrasound screening

  • Autopsy series discover ruptured AAA in 8 of 100,000 men and 3 of 100,000 women

  • Pathologically, AAAs show inflammation involving all 3 layers of the aorta and are characterized by loss of the media and fewer elastin fibers but more collagen

  • After age, smoking is the most common risk factor for AAA

  • Hypertension is associated with rupture but not the development of AAA. Other traditional atherosclerotic risk factors are not associated with AAA

    • – Family history may reveal a hereditary component in some cases

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Most are asymptomatic and found incidentally

  • Back, abdominal, or flank pain can occur

PHYSICAL EXAM FINDINGS

  • Pulsatile abdominal mass

DIFFERENTIAL DIAGNOSIS

  • Tumor adjacent to aorta

  • Pulsatile liver from tricuspid regurgitation

  • Musculoskeletal back pain

  • Acute abdomen (eg, pancreatitis)

  • Aortic dissection

  • Ureteric colic

DIAGNOSTIC EVALUATION

IMAGING STUDIES

  • Abdominal ultrasound is the best initial screening test and best test for serial follow-up

  • CT and MRI scanning are superior for identifying rupture in painful AAAs and planning therapeutic interventions

DIAGNOSTIC PROCEDURES

  • Angiography is often misleading and is not recommended

TREATMENT

CARDIOLOGY REFERRAL

  • Suspicion of heart disease before procedure or surgery

HOSPITALIZATION CRITERIA

  • Painful AAA

  • Ruptured AAA

  • Planned intervention

MEDICATIONS

AAA < 5.5 cm

  • Stop smoking

  • Treat hypertension

AAA > 5.5 cm

  • Repair unless risk is prohibitive

THERAPEUTIC PROCEDURES

  • Endovascular repair with a percutaneous graft-stent combination is performed in most cases

SURGERY

  • Surgical replacement with a synthetic graft if endovascular repair not feasible

MONITORING

  • ECG monitoring in hospital

  • Blood pressure in hospital

DIET AND ACTIVITY

  • Restrict activity if rupture suspected; exercise stress testing contraindicated

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • After successful procedure or surgery

FOLLOW-UP

  • If < 5.5 cm, repeat ultrasound: 3.0–3.4 cm, every 3 years; 3.5–4.4 cm, yearly; 4.5–5.4 cm, every 6 months

  • After endovascular repair, repeat CT or MRI at 1 month and 1 year and then yearly afterward

  • After surgical repair, repeat CT or MRI after 5 years

COMPLICATIONS
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