Abdominal Aortic

AneurysmOrla Dunlea

Neurosurgical 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