ABDOMINAL AORTIC ANEURYSM

Dr. Ayman Al-Attar MRCGP Int

Egyptian Fellowship in Family Medicine
Arab Diploma in Family Medicine
Professional Diploma in Diabetes
 A new book in the “Concise Medical
Guides” series , designed in organized
easy to recall way in order to be concise
yet comprehensive source covering
the “never to forget” issues in our
daily practice and the “high yield”
points commonly tested in board
exams. I hope it fulfils this aim and
may Allah grant success for all of us
 CONCISE MEDICAL GUIDES BY DR. AYMAN AL-ATTAR ABDOMINAL AORTIC ANEURYSM

❶ WHAT IS ABDOMINAL AORTIC ANEURYSM (AAA) ?

● DEFINITION AND PATHOPHYSIOLOGY :
- permanent pathological focal dilatation to more than 1.5 times normal
AP diameter. This is caused by degradation of elastin and collagen of
the arterial wall . Most AAAs begin below renal arteries and end above
iliac arteries . AAAs tend to enlarge by 0.2-0.8 mm/year and eventually
rupture (more in women). Many patients have concurrent thoracic aneurysms

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 CONCISE MEDICAL GUIDES BY DR. AYMAN AL-ATTAR ABDOMINAL AORTIC ANEURYSM

● ETIOLOGY AND RISK FACTORS :

- men are most commonly affected (4-6 times more than women)
- prevalence increases with age by about 6% per decade of life
- smoking is the most important and strongly related risk factor
- other risk factors include : positive family history in first degree relatives ,
atherosclerosis , hypertension , hyperlipidemia , COPD , vasculitis ,
trauma and connective tissue disorders as Marfan or Ehler-Danlos syndrome

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 CONCISE MEDICAL GUIDES BY DR. AYMAN AL-ATTAR ABDOMINAL AORTIC ANEURYSM

❷ WHEN TO SUSPECT ?
● PATIENT COMPLAINT :
- Asymptomatic : most AAAs are asymptomatic until they expand or
rupture and discovered incidentally on diagnostic imaging for other reasons
NB. Some patients may have vague symptoms of local compression
as early satiety , urinary symptoms , abdominal , back or groin pain

Expanding or Ruptured AAA : hypotension , tachycardia , altered mental

status and severe constant abdominal , low back , flank or groin pain

NB. > 50% of patient with ruptured AAA don’t survive to reach ER and
for those who survive the survival rate drops by about 1% per minute

● CLINICAL EXAMINATION :
- Pulsatile Epigastric Mass : classic finding but found in less than 50% of
patients and sensitivity varies with abdominal girth and aneurysmal size

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 CONCISE MEDICAL GUIDES BY DR. AYMAN AL-ATTAR ABDOMINAL AORTIC ANEURYSM

❸ HOW TO CONFIRM ?
● BEDSIDE USS :
- USS should be the first line workup for initial diagnosis and screening
- it can confirm presence and size of AAA but can’t rule out rupture
- the most accepted threshold for aortic diameter is 3 cm or more
● IMAGING STUDIES :
- CT/MRI : useful for anatomical mapping before surgical intervention
- Arteriography : primarily used intra-operatively to facilitate EVAR
- AXR : can show aortic calcification but not present in most patients
● LAB TESTS :
- consider CBC , clotting profile , cross matching , ESR and CRP

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 CONCISE MEDICAL GUIDES BY DR. AYMAN AL-ATTAR ABDOMINAL AORTIC ANEURYSM

❹ HOW TO MANAGE ?
● RUPTURED AAA :
- immediate resuscitation and referral for surgical intervention
- consider analgesia , perioperative antibiotics and VTE prophylaxis
- Endo Vascular Aneurysm Repair (EVAR) recommended in most patients

● UNRUPTURED AAA :
- Elective Surgical Repair : consider if > 5.5 cm and low surgical risk
- Risk Factors Control : smoking cessation and comorbidity control
- Follow Up : according to the following SVS 2018 recommendations :-
Every 3 y if 3-3.9 cm Every 1 year if 4-4.9 cm Every 6 mon if 5-5.4 cm

● USPSTF 2019 RECOMMENDATIONS FOR SCREENING :

- 1-Time Screening with USS : for all men 65-57 years who ever smoked
- Selective Screening with USS : for men 65-75 years who never smoked

● PATIENT EDUCATION :
- avoid strenuous exercises and lifting heavy objects
- keep healthy diet and adequate physical exercise

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 ‫‪CONCISE MEDICAL GUIDES BY DR. AYMAN AL-ATTAR‬‬ ‫‪ABDOMINAL AORTIC ANEURYSM‬‬

‫متدد األورطى‬
‫تم د د األورىط يع د د وج د د انتفد ددي ل اال د د اا د ددف مد ددر األورىط نخللد ددب وت د د ل وت د ددي‬
‫جا وايي خل د در اام د ددع اب ةد ددر د د اال د د ار ل األوةلد ددب اا م ود ددب وةد ددي مد ددي ي د د‬
‫إل‬ ‫ااك د د‬
‫ااتمد د ت د ددش م د ددت اا د ايل د در ااكت ود ددب وود د ا لمد ددي كمد د ور اا د ددش ووم د ددر يد د‬
‫ي‬ ‫ي‬
‫وا وتد ا‬ ‫وطي يه اا لي وود تط ذد ا اامد ر ارتطي يدي وًلبدي كياتد إل‬ ‫إل‬ ‫و نزوف او‬
‫ن ددطب وً ددي د إلدا اا ج دديش لط ددير اا ددر و ددم ة امد د اا طد د ر ي ددي تص ددتب اا د ايلد در وارتف ددي‬
‫األ يرب مر اا رجب األو‬ ‫ذ اا م وارتفي ضغ اا م ول اك وج تيروددخ م ضدي ةيئتدي ل‬

‫التشخيص ‪:‬‬
‫‪ -‬غتب اام ض يعين مر ة ار لث ُيكخ ف ب ك ةيرر ً دي جد ا ااف تدي‬
‫األة د ار ذا از ا ااتم د ب د و‬ ‫و ت د‬ ‫اا وت لددب و ااف ددط ااط د ا أل ددطيب و د‬
‫تغي رجب اا ةدي وان فير ضغ اا م‬ ‫انفل لث يعين اامروض مر ام ش ي ل ااططر مع إل‬
‫ممي نهي ت ج ل غتب اام ض‬ ‫‪ -‬وبف ط كطر اامروض ت ج لتتب نيك ب وه ة مب إل‬
‫ي‬
‫‪ -‬ووتم ااخ لط ةر روق اام جي ف ق ااص تلب ة ااططر كمي ي صح ي يي إج ا م ح ا‬
‫كيا نير الميع اا جيش اا ير رتياوح ةميرذم لدر ‪ 65‬و ‪ 75‬ب وو و ا يالي و و ا مر ط‬
‫ايا‬ ‫‪ -‬كمي يم ر تأكل ااخ لط ةر روق األشعب اامبطعلب و اا إلنا اامغ ي يس و تص و ر‬
‫ااش إل‬

‫العالج ‪:‬‬
‫اا ك ل انفلير ااتم اا ةين‬ ‫كي مر ‪ 5.5‬م و ل ي‬ ‫ر‬ ‫ااتم اا ي‬ ‫‪-‬ل ي‬
‫تتم اي ياب ج ا ب األوةلب اا م وب يج ا اات و اال اح اا زم ينبيذ لي اامروض‬
‫ي‬
‫‪ -‬ل اا ددي األود اام ددتب يم ددر متيكعتهددي كيا د نير وروددي ددب طد ااتمد اا ةددين كد ‪3‬‬
‫ب ذا كي ‪ 4.9-4‬م و ك تب شه ذا كي ‪ 5.4-5‬م‬ ‫إلا ذا كي اابط ‪ 3.9-3‬م و ك‬
‫‪ -‬وذاك جينب اا لط ة ة ام اا ط ر ةر روق ا رايام كع ج ارتفي اا غ و ذ اا م‬
‫ي ددلب ام ددع تف ددي م اام د ر وتبتل د‬ ‫وا ل ط د‬
‫‪ -‬ي ص ددح اام ددروض ك د د ور اي د ة ددر اات د إل‬
‫ف تب و ا نفلير واايوف كمي ي صح كيتطي نظيم غ ان تح وة م م شلي ًبلتب‬

‫‪6‬‬
CONCISE MEDICAL GUIDES
made to be easy for student , concise for GP and basic for intern

A new book in the “Concise Medical Guides” series ,

designed in organized easy to recall way in order to be
concise yet comprehensive source covering the “never
to forget” issues in our daily practice and the “high
yield” points commonly tested in board exams. I hope
it fulfils this aim and may Allah grant success for all of us