Abdominal aortic aneurysm natural history, complications and prognosis
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Abdominal Aortic Aneurysm Microchapters |
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Differentiating Abdominal Aortic Aneurysm from other Diseases |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: : Ramyar Ghandriz MD[2]
Overview
An aortic aneurysm can progress to a ruptured abdominal aortic aneurysm, which is a medical emergency associated with an extremely high mortality. Serious complications can also occur as a result of an aortic dissection, such as myocardial infarction, shock, stroke, kidney failure, and arterial emboli. A ruptured AAA carries an overall mortality rate approaching 75%, which is much higher than the mortality rate of 2-6% in those patients who underwent elective surgical repair. Approximately 16% of large AAAs (diameter >5.5 cm) rupture, causing 9,000 AAA-related deaths in the United States per year. Several studies have shown that screening can drastically reduce the aneurysm rupture rate by 45-49% for men older than 60, and reduce AAA-related mortality by 21-68%.
Natural History, Complications, and Prognosis
Natural History
Abdominal aortic aneurysms expand slowly over time. It is for this reason that ultrasound surveillance is recommended. The risk for rupture of an aneurysm depends on several factors[1]:
- Size of an aneurysm
- Risk of rupture increases greatly once the size of aneurysm reaches 5.5 cm.
- Rate of expansion
- If the rate of expansion exceeds 1 cm per year, this is an indication for surgery.
- Growth tends to be more rapid in smokers than non-smokers.
- Gender
- The risk of rupture is higher in women than in men.[2]
Complications
- When an abdominal aortic aneurysm ruptures, it is a true medical emergency.
- Aortic dissection occurs when the innermost lining of the artery tears and blood leaks into the wall of the artery.
- This most commonly occurs in the aorta within the chest.
- Complications include:[3]
- Aortic rupture:
- Once an aneurysm has ruptured, it presents with a classic pain-hypotension-mass triad.[4]
- The pain is classically reported in the abdomen, back or flank. It is usually acute, severe and constant, and may radiate through the abdomen to the back.
- The diagnosis of an abdominal aortic aneurysm can be confirmed at the bedside by the use of ultrasound.
- Rupture is indicated by the presence of free fluid in potential abdominal spaces, such as Morrison's pouch, the splenorenal space, subdiaphragmatic spaces and peri-vesical spaces.
- A contrast-enhanced abdominal CT scan is needed for confirmation. Only 10-25% of patients survive a rupture due to large pre and post-operative mortality.
- Annual mortality from ruptured abdominal aneurysms in the United States alone is about 15,000.
- Aortic rupture:
- Acute aortic occlusion
- Aortocaval or aortoduodenal fistulae
- Arterial embolism
- Disseminated intravascular coagulation
- Heart attack
- Hypovolemic shock
- Kidney failure
- Stroke
Prognosis[5]
Elective Surgery in the Absence of Abdominal Aortic Aneurysm Rupture
The outcome is usually good if an experienced surgeon repairs the aneurysm before it ruptures.
Emergency Surgery in the Setting of Abdominal Aortic Aneurysm Rupture
Rupture of an abdominal aortic aneurysm is associated with a 60% to 90% mortality before the patient reaches a hospital. It is associated with a 30% to 80% operative mortality among those patients who survive long enough to undergo surgery.
Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Aortic Aneurysm Rupture[6]
| Class I |
| "1. Patients with infrarenal or juxtarenal AAAs measuring 5.5 cm or larger should undergo repair to eliminate the risk of rupture. (Level of Evidence: B)" |
| "2.Patients with infrarenal or juxtarenal AAAs measuring 4.0 to 5.4 cm in diameter should be monitored by ultrasound or computed tomographic scans every 6 to 12 months to detect expansion. (Level of Evidence: A) " |
| Class IIa |
| "1.Repair can be beneficial in patients with infrarenal or juxtarenal AAAs 5.0 to 5.4 cm in diameter. (Level of Evidence: B)" |
| "2.Repair is probably indicated in patients with suprarenal or type IV thoracoabdominal aortic aneurysms larger than 5.5 to 6.0 cm. (Level of Evidence: B)" |
| "3.In patients with AAAs smaller than 4.0 cm in diameter, monitoring by ultrasound examination every 2 to 3 years is reasonable. (Level of Evidence: B)" |
| Class III |
| "1.Intervention is not recommended for asymptomatic infrarenal or juxtarenal AAAs if they measure less than 5.0 cm in diameter in men or less than 4.5 cm in diameter in women(Level of Evidence: A)" |
References
- ↑ Gillum RF (1995). "Epidemiology of aortic aneurysm in the United States". Journal of Clinical Epidemiology. 48 (11): 1289–98. PMID 7490591. Retrieved 2012-10-27. Unknown parameter
|month=ignored (help) - ↑ Norman PE, Powell JT (2007). "Abdominal aortic aneurysm: the prognosis in women is worse than in men". Circulation. 115 (22): 2865–9. doi:10.1161/CIRCULATIONAHA.106.671859. PMID 17548742. Unknown parameter
|month=ignored (help) - ↑ Macaluso CR, McNamara RM (2012). "Evaluation and management of acute abdominal pain in the emergency department". Int J Gen Med. 5: 789–97. doi:10.2147/IJGM.S25936. PMC 3468117. PMID 23055768.
- ↑ David, James K.; Bornstein, Sue S.; Myers, Lyndakay G. (2017). "Abdominal Aortic Aneurysm". Baylor University Medical Center Proceedings. 13 (1): 89–93. doi:10.1080/08998280.2000.11927648. ISSN 0899-8280.
- ↑ Gawenda, Michael; Brunkwall, Jan (2012). "Ruptured Abdominal Aortic Aneurysm". Deutsches Aerzteblatt Online. doi:10.3238/arztebl.2012.0727. ISSN 1866-0452.
- ↑ Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 61 (14): 1555–70. doi:10.1016/j.jacc.2013.01.004. PMC 4492473. PMID 23473760.