Abdominal Aortic

Aneurysm

Abdominal Aortic

Aneurysm

Orla DunleaNeurosurgical Registrar

Orla DunleaNeurosurgical Registrar

What is it?

Infrarenal

>50% over normal artery

diameter

Retro-peritoneal

Inferior Mesenteric

artery sacraficed

Natural history is to enlarge & rupture,

unless die from other

causes

What causes it?

How does it present?

Lay your hands on me

• Most aneurysms are picked up incidentally - either by a clever doctor or scan

• Take a minute to palpate your patient’s abdomen, regardless of the reason you are seeing them

Even a plain abdominal x-ray (especially lateral) can be a clue with calcification outline

Feel your way

• General

• Patient laying flat with 1 pillow

• Pulsatile swelling in the upper abdomen

• Stable/in shock

• Pulse - regular/irregular - no delay

• ?Carotid bruit

Examination of AAA patient

• Abdomen

• Inspection - sternotomy scar, abdominal scar

• Palpate - ?tender to touch (worry) expansile/pulsatile/diameter/upper limit/side to side

• Groin - ?femoral pulses/femoral aneurysms

• Auscultate for bruit

• Peripheral vascular examination (popliteal aneurysm)

Size Matters

• How big is it?

• <5cm - follow up

• >5cm likely need intervention

• If <5cm but increasing in size quickly = intervention

Except for women

Investigations• Ultrasound

• Screening

• Initial diagnosis

• Relationship to renal arteries

• Not helpful if obese

Investigations

• CT

• If obese

• Planning surgery

Other investigations

• CTA/MRA/Angiogram

• Bloods including G&S & coag

• ECG

• CXR

• Echo

• PFTs

In Theatre• Timeout

• GA

• Arc line

• Catheter

• NG

• ABs

• Fluids

• Cell saver

Layers

• Skin

• Anterior layer of rectus sheath/linea alba

• Rectus abdominus muscles

• Posterior layer of rectus sheath

• Transversalis fascia

• Extra-peritoneal fat

• Peritoneum

• Greater omentum/Stomach/transverse colon

• Small intestine & mesentery/pancreas/duodenum

Post operativeImmediate

HaemodynamicsFluid balance

Pulses1 Pneumonia - 5%2 Myocardial infarction - 2-5%3 Groin infection - Less than 5%4 Graft infection - Less than 1%5 Colon ischemia - Less than 1% if elective and 15-20% if ruptured6 Renal failure related to preoperative creatinine level, intraoperative cholesterol embolization, and hypotension7 Incisional hernia - 10-20%8 Bowel obstruction9 Amputation from major arterial occlusion10 Blue toe syndrome and cholesterol embolization to feet11 Impotence in males - Erectile dysfunction and retrograde ejaculation (>30%)12 Paresthesias in thighs from femoral exposure (rare)13 Lymphocele in groin - Approximately 2%14 Late graft enteric fistula15 Death - 1.8-5% if elective and 50% if ruptured

Later

EVAR

2000Up to 10%

repeat procedure

Co-morbidities