management of aaa andrew stanley, md 2006. history hpi hpi 73 yo woman presenting to vascular clinic...

Management of AAAManagement of AAA

Andrew Stanley, MDAndrew Stanley, MD20062006

HistoryHistory HPIHPI 73 yo woman presenting to vascular clinic for routine follow 73 yo woman presenting to vascular clinic for routine follow

up for AAA. Last measured (6 months prior) AAA size was up for AAA. Last measured (6 months prior) AAA size was 4.0cm. In clinic pt reports some recent back pain in last 2 4.0cm. In clinic pt reports some recent back pain in last 2 weeks. Other than that pt is jogger and exercises avidly.weeks. Other than that pt is jogger and exercises avidly.

PMHPMH HysterectomyHysterectomy HTNHTN

MedsMeds HCTZHCTZ CozaarCozaar ASAASA

Shx-Never smoker/Retired accountant/clerical-type worker. Shx-Never smoker/Retired accountant/clerical-type worker. Living independently with local familyLiving independently with local family

Fhx-no known AAA hxFhx-no known AAA hx

PhysicalPhysical

P.E BP Rt-180/70 Lt (same)P.E BP Rt-180/70 Lt (same)Neck-No carotid bruitsNeck-No carotid bruitsLungs-ClearLungs-ClearHeart-RegularHeart-RegularAbd-Tender RLQ with pulsatile massAbd-Tender RLQ with pulsatile massNormal pulse exam.Normal pulse exam.

U/S shows growth from U/S shows growth from 4.0-5.5 cm in 6 months.4.0-5.5 cm in 6 months.

What to do?What to do? Back in 6 monthsBack in 6 months Send for cardiolite/repair if possible in Send for cardiolite/repair if possible in

next 1-2 monthsnext 1-2 months CT to R/O leak.CT to R/O leak.

What To Do/When To Do ItWhat To Do/When To Do It

CT-5.5 cm AAA with 4.5cm right CT-5.5 cm AAA with 4.5cm right common iliac AAA. No leak. Options common iliac AAA. No leak. Options includeinclude

Fix in next 24 hours.Fix in next 24 hours. Schedule follow up visit to discuss Schedule follow up visit to discuss

repair following cardiolite or repair following cardiolite or ECHOcardiogram.ECHOcardiogram.

GROWTHGROWTH

What is rapid rate of growth (for What is rapid rate of growth (for AAA)?AAA)?

What is average rate of growth (for What is average rate of growth (for AAA)?AAA)?

What is size at which iliac aneurysms What is size at which iliac aneurysms are considered for repair?are considered for repair?

Had AAA repair with Had AAA repair with uneventful hospital uneventful hospital

course course

Follow-Up/Counseling IssuesFollow-Up/Counseling Issues

In clinic post-op---significant issues In clinic post-op---significant issues are:are:

Other possible locations for aneurysmal Other possible locations for aneurysmal degenerationdegeneration

Familial counseling (AAA risk)Familial counseling (AAA risk) KidsKids SistersSisters BrothersBrothers

Any follow up imaging needed following Any follow up imaging needed following open AAA repair in a 73yo woman?open AAA repair in a 73yo woman?

SummarySummary

Abdominal pain in presence of Abdominal pain in presence of significant AAA (especially one that significant AAA (especially one that has demonstrated recent substantial has demonstrated recent substantial growth) should be considered sign of growth) should be considered sign of impending rupture. In this setting it impending rupture. In this setting it is uncommon to find good reason to is uncommon to find good reason to rationalize any preop risk stratifying rationalize any preop risk stratifying testing (cardiolite/PFT/labs) prior to testing (cardiolite/PFT/labs) prior to repair. Urgent repair is the rule.repair. Urgent repair is the rule.