Pathologic

focal dilation of the aorta that is >30 mm or 1.5 times the diameter of the normal aorta 90% are infrarenal in location & have a fusiform morphology Etiology of most aortic aneurysms is atherosclerotic

AAA : staccato pattern of growth Average growth: approx. 3-4 mm/year The larger the aneurysm, the faster it expands Rupture risk: directly related to aneurysm size; maximum transverse diameter standard method of risk assessment Women are at higher risk for rupture Unless symptomatic or ruptured, repair is prophylactic

Description

Diameterof Aorta (cm)

2-3

Est. Annual Risk of Rupture (%)

0

Est. 5-y Risk of Rupture (%)

0 (unless AAA develops) 5-10 30-40 >50

Normal aorta

Small AAA Moderate AAA Large AAA

4-5 5-6 6-7

1-5 2-5 3-10

Very large AAA

>7

>10

Approaching 100

Most are asymptomatic P.E.: neither sensitive nor specific, except in thin patients If the pt. is hemodynamically stable & the aneurysm is intact in CT scan: admitted for BP control with IV antihypertensive agents & repaired w/in 12-24 hrs or during the same day

Pts. who are hemodynamically unstable with history of acute back pain and/or syncope, w/ known ruptured AAA or pulsatile abd. mass immediately to the OR of all pts. w/ ruptured AAA die before reaching the hospital Surgical mortality 45 to 50%

Preoperative evaluation includes routine history & P.E with particular attention to:
a) Any symptoms referable to aneurysm b) History of pelvic surgery or radiation c) Claudication suggestive of significant iliac occlusive disease d) LE bypass or other femoral reconstructive procedures e) Chronic renal insufficiency or contrast allergy

Cross sectional imaging is required for definitive evaluation of AAA CT scan- gold standard for determination of anatomic eligibility for endovascular repair Major drawback in CT scan: risk of contrast nephropathy in diabetics & pts. w/ renal insufficiency Conventional angiography- minimal role in the current management of AAA & invasive with increased risk of complications

General anesthesia is necessary in conventional open AAA repair Midline transabdominal incision common approach for open aortic aneurysm operation Tube graft used to replace the aorta if the aneurysm only involved the abd. aorta Prosthetic bifurcated graft used for either an aortobi-iliac or aortobifemoral bypass reconstruction

ADVANTAGES
AAA is permanently eliminated Direct assessment of the circulatory integrity of the colon Permits the surgeons to explore for other abd. pathologies

RISKS
Cardiac complications (M.I or arrhythmias) Renal failure or transient renal insufficiency Ischemic colitis Prosthetic graft infection 1 to 4%

Implantation of an aortic stent graft that is fixed proximally & distally to the nonaneurysmal aortoiliac segment, thereby excludes the aneurysm from the aortic circ. Minimally invasive Alternative for pts. who are at inc. risk for surgery d/t their age or comorbidity Does not remove or eliminate the aneurysm sac w/c is potential for expansion or rupture Aortic branches are ligated

Based on 3 areas: 1. Proximal Aortic neck 18 to 28 mm in diameter & min. length of 15 mm 2. CIAs distal landing zone; treatable diameter- 8 to 20 mm 3. Ext. iliac & common femoral arteries *all diameter measurements are midwall to midwall of the vessel

Secondary considerations:
Angular calcifications (<50% circumference) Luminal thrombus (<50% circumference) Angulation (<45 degrees) *Presence of a significant amt. of any one of these in combination w/ short proximal neck may compromise successful short- & long-term fixation of the stent graft.