1. Abdominal Aortic Aneurysms
By Theodore Graphos

2. PATIENT CASE
52 y/o male presenting to MMC for an elective
abdominal aortic aneurysm (AAA) repair.
Presentation Labs/Vitals
 Palpable pulsitile mass in Temp: 36.7 C
the epigastric area HR: 62
 Intermittent abdominal pain RR: 16
 Abdominal CT BP: 117/83
 7.9 cm AAA
 Large mural thrombus 146 4.2 6
116
completely occluding 106 28.8 0.79
the vessel lumen

3. PATIENT CASE
52 y/o male presenting to MMC for an elective
abdominal aortic aneurysm (AAA) repair.
PMH Meds
1. AAA (Dx in 2010) Tramadol
2. Hypertension Simvastatin
3. Hyperlipidemia Amlodipine
4. Depression Metoprolol
5. Intermittent claudication Zolpidem
6. Smoking

4. PATIENT CASE
52 y/o male presenting to MMC for an elective
abdominal aortic aneurysm (AAA) repair.

5. PATHOPHYSIOLOGY
AAAs develop as a result of chronic aortic wall
inflammation 4
Arterial injury
 Hypertension
 Hyperlipidemia
 Toxins (nicotine)
Inflammation
Degradation of elastin
AAA growth & rupture

6. 7
EPIDEMIOLOGY
>32,000 cases in the U.S. every year
75% of aneurysms ≥4 cm in diameter can be
positively liked to a history of smoking
♂ Men are at 4-6 times greater risk of
developing an AAA
Incidence increases with age
Affects 2-5% of men >50 yrs; Rare in patients <50 yrs
Positive family history of AAA can
double the risk

7. 2,7
PRESENTATION
 Most AAAs are small and are discovered incidentally
 Insidious development, rarely causing symptoms
Symptoms
 Pain
 Dull, vague pain in the abdomen, back, or flank
 Can be acute and severe in ruptured AAAs
 Mass
 Sensation of a pulsitile mass in the abdomen
 Hypotension
 Usually manifesting as syncope
 Occuring in cases of ruptured AAAs

8. 2
PRESENTATION
Associated complications
 Diminished femoral pulses
 "Blue Toe" Syndrome
 D/t microemboli from aortic
thrombus
 Duodenal obstruction
leading to vomiting and
weight loss
 Vertebral body erosion
leading to severe back pain

9. PRESENTATION
Risk of rupture AAA Diameter Rupture risk 5
is dependent on… (cm) (%/yr)
<4 0
 Diameter 4-5 0.5-5
 Shape 5-6 3-15
(Fusiform < Saccular) 6-7 10-20
7-8 20-40
 Growth rate >8 30-50
Repair is recommended for… 6
 Fusiform AAAs ≥ 5.5 cm in diameter
 Pts presenting w/ back or abdominal pain

10. TREATMENT

11. TREATMENT
AAA Diagnosed
Small/Stable AAA
Large/Unstable AAA
Ruptured AAA
Surveillance
Surgery
6
Goal:
Slow the rate of AAA growth such that it
does not reach the threshold for rupture
within the patient’s lifetime

12. TREATMENT SURVEILLANCE
Smoking Cessation Recommended Strong High
The single, most important modifiable risk-factor
12
Review Human (N>3 million) Smoking was associated with a 3- to 6-fold
increased risk of an aortic aneurysm
Statins Recommended Weak Low
16
Observational AAA patients Statin use was associated with a
(N=150) significantly decreased rate of AAA growth
(1.16 mm/yr less than non-users).
17
Observational AAA patients Statin use was associated with significantly
(N=130) less AAA growth at an average follow-up of
4 years (p<0.001)

13. TREATMENT SURVEILLANCE
ACE Inhibitors Insufficient Ev idence Weak Low
10
Observational AAA patients Use of ACE inhibitors was less frequent in
(N=15,326) patients who presented to the hospital
with a ruptured AAA.
Doxycycline & Insufficient Ev idence Weak Low
Roxithromycin
1
Experimental AAA patients Doxycycline 6-mo course significantly
(N=36) reduced mean MMP-9 levels
13
RCT AAA patients Aneurysm expansion was significantly
(N=32) slower in the doxycycline group at >6 mo.
18
RCT AAA patients Aneurysm expansion was significantly
(N=92) slower in the roxithromycin group over the
first year

14. TREATMENT SURVEILLANCE
Beta-Blockers NOT Recommended Weak Low
11
Observational AAA patients Patients receiving a beta-blocker had a
(N=27) significantly slower rate of AAA growth.
9
Observational AAA patients Patients receiving a beta-blocker had a
(N=121) significantly slower (p=0.02) rate of AAA
growth.
20
RCT AAA patients Patients receiving propranolol had a non-
(N=548) statistically-significant difference in AAA
growth rate (p=0.11) and mortality (p=0.36)
19
RCT AAA patients Patients receiving propranolol had a non-
(N=477) statistically-significant difference in AAA
growth rate (p=0.48)

15. 6
TREATMENT SURGERY
Pre-Operative
 Antibiotic prophylaxis
 1st or 2nd generation cephalosporin or vancomycin
 Within 30 minutes of incision
 Continued for no more than 24 hours post-op
Post-Operative
 Analgesia
 Epidural or PCA after an open AAA repair
 DVT prophylaxis
 SCDs and early ambulation for all patients
 Anticoagulant therapy for patients at high risk of
developing a DVT

16. TREATMENT SURGERY

17. 8
TREATMENT SURGERY
 Beta-blockers, statins, alpha-2
agonists, and calcium channel blockers to
reduce cardiac risk
 Pain management
 VTE prophylaxis
 Glucose control
 Post-operative arrhythmias
 Beta-blockers are the preferred agent for patients with
a post-operative supraventricular arrhythmia
 Cardioversion is only recommended in hemodynamically
unstable patients

18. TREATMENT SURGERY
 No guideline-supported recommendations
for post-operative hyper- or hypotension
after AAA repair.
 Typically, a MAP that differs from pre-operative readings
by >20% should be treated. 15

19. PATIENT CASE
4/17 OR for AAA repair. Aortic bifemoral bypass graft
placed. BP managed with nitroprusside drip.
4/19 Pt extubated and off sedation and nitroprusside.
4/20 Pt desatted and was reintubated. W/u revealed CAP
and L-sided PTX. EKG revealed pt was in a-fib w/
RVR. Abx for CAP and metoprolol for a-fib.
4/23 Pt extubated and recovering from CAP.
4/25 Pt back to NSR. Out to floor.
4/27 Discharged to home.

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