Thoracic Aortic Aneurysms
Abdominal Aortic Aneurysm (AAA)
Diff: renal colic, diverticulosis, GI hemorrhage, acute MI and back pain
Most are infrarenal (90%)
Normal aorta is 2 cm,>3 cm is AAA
Family history is a strong predictor
Pain, sense of abd fullness, pulsations
Should not feel pulsations to the R of the umbilicus(this is where aorta bifurcates as well)
Livedo reticularis-cyanotic, cool, pale, painful toes
Can compress adjacent structures or fibrose
Rupture-pain, hypotension, pulsatile abd mass, syncope
Studies: x-ray useless, bedside UTS or CT (do not need contrast to see aneurysm, might need it to see rupture, but in the right setting, aneurysm=rupture)
Presents as GI bleeding
Aortovenous-bruit, high output cardiac failure
Appears on radiograph, UTS, CT
T+C 10 units if rupture
Complications post repair-graft infxn, fistula, anastomic aneurysm
Case 3: 69 year old male is brought to the ED by paramedics for acute LLQ pain and hematuria. The pain is 7/10, colicky, sharp, and worse when standing. He also complains of mild SOB and sweating off and on today but denies cough, CP, fever, nausea, vomiting or diarrhea. PMH is significant for CAD, CHF, CVA’s, HTN, NIDDM, and an appendectomy. His medications include glyburide, HCTZ, Lopressor, and K+.
Physical exam: WNWD male “relaxed, pale, and diaphoretic”. HR 94, BP 127/84, RR 26, T 37.1°C. RESP: mild right basilar crackles, CV: irregular without murmurs, GI: obese and soft with moderate LLQ tenderness, EXT: no edema and normal pedal pulses. BACK: no CVA tenderness. Rectal: 2+ prostate, heme negative brown stool.
· Aortic dissection
· Diabetic ketoacidosis
· Mesenteric Ischemia
Genital exam: normal
EKG: Atrial fibrillation without signs of ischemia
UA: WBC 3, RBC 1
Chest X-ray: Cardiomegally, mild CHF
Bedside glucose: 190
Next diagnostic test of choice? Doesn’t Nephrolithiasis cause more than 1 RBC on urinalysis?
In the ED we always need to rule out life threatening causes. Given the non-specific nature of this patient’s pain and risk factors one must consider the three vascular abdominal emergencies in the elderly: a leaking AAA, mesenteric ischemia, and myocardial infarction.
In this case the treating physician suspected nephrolithiasis and ordered a KUB and then an IVP. What is the role of abdominal x-rays in the work up of abdominal pain? Is a KUB a good screening x-ray or should an “abdominal series” be ordered?
Abdominal Radiographs in Patients with Abdominal Pain
· An “abdominal series” should at least include upright chest in addition to supine abdomen to look for free air under the diaphragm.
· Suspected pathology indications:
· A KUB is not a good screening x-ray even for nephrolithiasis. Even though textbooks state that 90% of kidney stones are visible on radiograph (outside of the patient), less than 10% can be seen on prediagnosis x-ray (with in the patient).
The KUB interpreted by the radiologist while the IVP was being done showed a large calcified AAA.
Stat Surgical Consult.
Hospital course. Over the phone the surgical consult suggested that an abdominal CT scan be performed to delineate whether or not the aneurysm was ruptured (because repair of symptomatic, but not ruptured AAA has a much lower mortality if performed electively rather than emergently). Twenty minutes later a CT scan confirmed a ruptured AAA. The patient became hypotensive with a SBP in the 60’s and 70’s. He received 4 liters of saline and 4 units of O negative blood in an effort to “stabilize” him so he could be taken to surgery. Although his blood pressure transiently increase, he arrested as he was being wheeled into the OR and could not be resuscitated.
Abdominal Aortic Aneurysm
· Localized dilatation of aorta involving all layers of vessel wall
· 2-4% prevalence over age 50
· 10% prevalence over age 80
· Five times more common in males
· Cause currently unknown
· Associated with long history of hypertension and atherosclerosis
· Without rupture or leakage, most are asymptotic
· With rupture
1) Abdominal or back pain
3) Exam may be misleading: often without significant tenderness, may not palpate a pulsatile mass: cannot rule out AAA base on exam (Lederle).
· Not helpful in excluding diagnosis
· Hematuria is common and does not help differentiate AAA from nephrolithiasis (7/15 microscopic and 6/15 gross hematuria in study by Pomper 1995 where as Bove found that 33% of patients with CT documented nephrolithiasis had a urinalysis with fewer than 5 RBC and 11% had no RBC).
· Plain film radiographs
1) Suggests AAA 60% of the time
2) Best view is lateral lumbar spine file
3) Should never be used to rule out AAA
1) Can diagnose the presence or absence of an AAA
2) Will not differentiate whether or not AAA is leaking or ruptured
3) Allows for continued careful monitoring of patient
4) Operator dependent, however a recent study has shown ED physicians to be very (100%) accurate for detecting AAA with only 2/68 scans being indeterminate.(Kuhn)
· CT Scan of abdomen
1) Diagnoses the AAA if it is leaking or ruptured
2) Patient must leave the department
3) Less operator dependent
4) Excellent at diagnosing other pathology
5) Scans for nephrolithiasis will diagnose AAA (Nachmann)
1) Less sensitive than other modalities and more invasive
2) Main role is preoperative evaluation of elective AAA repair
3) No role in emergency evaluation of suspected leaking AAA
· For leaking AAA
1) Immediate surgical consult
2) Fluid/blood transfusion: controversial, some data suggests “hypotensive hemostatis” and withholding fluids and blood until SBP drops below 50mmHg. (Bickell)
3) Mortality 100% without surgery; 50% with surgery overall: mortality greater when rupture occurs into abdominal cavity (Satta 1998)
4) Even symptomatic, but radiographically “unruptured” AAA should be operated on emergently and do not have a higher mortality when performed emergently than electively.(0/9 versus 5/18 in one series, Adam)
5) One recent study found that emergency surgery in patients over 80 years of age only prolonged life by an average of 1 week. (Robinson 1997)
6) Cutting Edge: Emergently Placed Endovascular Grafts
a) Landmark Study: Ohki and Veith
b) Used a transbrachial balloon to achieve hemostasis in patients with 25 patients with ruptured AAA
c) 20 patients were stented with a “one-size-fits-all” graft; 5 needed open laparotomy
d) 23/25 survived to hospital discharge
e) Amazing results in study that included unstable patients
f) Currently limited to major vascular surgery center: should be available more broadly in 2 years
· For asymptomatic non-ruptured AAA
1) Refer for elective surgical or transfemoral repair
2) Treatment of even small aneurysms shown to improve survival in almost all patients: even octogenarians
3) Elective repair mortality: 1-5%
1) Always consider the diagnosis of AAA first in vasculopaths with signs and symptoms of nephrolithiasis.
2) Utilized helical CT to diagnose nephrolithiasis rather than IVP when available.
3) For patients with suspected AAA rupture or leaking: Call a surgeon and ready the OR immediately; don’t delay the call for diagnostic studies.
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