Inflammatory Abdominal Aortic Aneurysm with

Obstructive Nephropathy in a 71 yr old Male

ByChijioke Chinaka

• HS, 71 yr Old Male– Background

• Hypertension• Asthma

• T/F a peripheral Hospital – Incidental finding of 10cm Non leaking AAA– On treatment for PE

• Presentation– Left upper leg pain– Swelling– Cellulitis on the foot– Abdominal pain0, back pain0, urinary symptoms0

• Examination/investigations – Swollen tender upper left leg; Duplex scan– LIF mass; CT

CT SCAN•Inflammatory Aneurysm

•Hydronephrosis

•Over Distended Bladder

•Bilateral thrombo ilio-femoral veinous system

Hydronephosis Over distended blader

Thrombosed ilio femoral venous system

Sagittal section

• Examination– Pulse 90b/min– BP 120/80 mmHg– Left Lower limb

• Mildly swollen• Groin tenderness• Cellulitic dorsum of foot

– Abdomen• Soft• Non tender pulsatile mass

• Investigation– Bloods: Cr – 140 mmol/l, Urea – 4.1 mmol/l, CRP – 71, ESR

– 42mm/hr, WCC – 8.78, Hb – 11.6

• Impression - Inflammatory Aneurysm• Issues– Non Ruptured massive AAA– Bilateral Hydroureter– Poor Renal Function

• Plan– Urology consult– Nephrology consult– Work up for optimization– Urgent surgery

• Nephrology– Continue protective measures– N-acetyl cysteine– Fluids

• Urology– Hydronephrosis 20 ?Bladder outlet obstruction– USS– PSA

• USS– Bladder not trabeculated– Prostate not enlarged– Kidney

• Right 9.7cm• Left 9.5cm

– Right Hydronephorosis– No evidence of left

hydronephrosis

• PSA– Total PSA 2ng/ml– Free PSA 0.5ng/ml– Ratio 25%

• Cr - 105, Echo – EF 50%, • Surgery (2 options)– Open Repair• Complicated• Difficult access• Fistulation

– Endovascular Stenting (EVAR)• Suitability• Minimal access

• EVAR(surgery)– 6th Day– Aorto – iliac + Fem - Fem cross over

• Post Op– Resolved left hydronephrosis– Persistent right

DISCUSION

Inflammatory Abdominal Aortic Aneurysm

• Definition– A distinct sub group of AAA– exuberant inflammatory reaction – marked peri-aneurysmal and retroperitoneal fibrosis – dense adhesions of adjacent abdominal organs

• Incidence– 5% to 10% of all AAA– > Male (M:F = 30:1 to 6:1)– Mean Age; 62 to 68 yrs– Smokers 77% to 100%

• Aetiology– Unknown >90%– Genetic factor (HLA –DR B1 locus)

• + ve FHx (17%)

– Unlikely infective aetiology : Chlamydia pneumoniae.– ?variant of retroperitoneal fibrosis.

Walker et al. Br J Surg 1972;59: 609 -14, T. Tang et al EJVES Vol 29 Issue 4, 2005; SS Nitecki et al J Vasc Surg 23 (1996) (5), pp. 860–868.

• Pathophysiology– Inflammation

• Inflammatory cell infiltrate• Both in IAAA and non – IAAA but > in the later• Macrophages, T- lymphocytes and B- lymphocytes• Immune Response

– Infection• Herpes simplex and Cytomegalovirus• Chlamydia pneumonia

• Presentation – Symptoms

• Usually symptomatic (80%)• Abdominal pain + back pain• Weight loss• Asymptomatic (20%)

A. Stella et al Ann Vasc Surg 7 (1993), pp. 229–238.

– Signs• Tender pulsatile abdominal mass (15% to 30%)• Elevated ESR (40% to 88%)• Raised CRP• Auria (Rare)

– Others• Ischaemic foot• Intermitent claudication

• Diagnosis– CT Scan

• Sensitivity 83.3%• Specificity 99.7%• Overall accuracy 93.7%

– Ultrasound Scan– MRI– Nuclear Medicine

Inflammatory AAA

• Younger patient• Usually symptomatic• Elevated inflammatory

maker• Marked thickening of

Aneurysmal wall• Fibrosis of Adjacent

retroperitoneun• Less likely to rupture• Strongly related to smoking

Atherosclerotic AAA

• Older patient• Usually asymptomatic• Unrelated

• Less thickening of wall

• Less fibrosis

• More likely to rupture

Treatment

• Non Operative– Extensive fibrosis– Steroid therapy– Risk of Rupture

• Operative– Open Surgery

• High technical difficulty• Increased morbidity/mortality rate• Longer operating time • Longer hospital stay

– EVAR• Longer-term peri aneurysmal regression

• Uretrolysis/Management of Related Pathology