Sandbox Yaz: Difference between revisions
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{{familytree/start |summary=AAA Treatment Algorithm.}} | {{familytree/start |summary=AAA Treatment Algorithm.}} | ||
{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | |A01=Confirmed AAA}} | {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; width: 18em; padding:1em;">Confirmed AAA</div>}} | ||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | |B01=Symptoms present?}} | {{familytree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 18em; padding:1em;">Symptoms present?</div>}} | ||
{{familytree | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | | | | | | | | |}} | {{familytree | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | C01 | | | | | | | | | | | | C02 | | | | | | | | | | | |C01=No | C02=Yes }} | {{familytree | | | | | | | | C01 | | | | | | | | | | | | C02 | | | | | | | | | | | |C01=No | C02=Yes }} | ||
{{familytree | | | | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | | | | | |}} | {{familytree | | | | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | D01 | | | | | | |,|-|-|-|-| D02 | | | | | | | | | | | |D01=❑Perform imaging using ANY of the following imaging modalities for the abdominal aorta and iliac arteries:<br> | {{familytree | | | | | | | | D01 | | | | | | |,|-|-|-|-| D02 | | | | | | | | | | | |D01=<div style="float: left; text-align: left; width: 18em; padding:1em;">❑Perform imaging using ANY of the following imaging modalities for the abdominal aorta and iliac arteries:<br> | ||
❑ Ultrasound | ❑ Ultrasound | ||
❑ CT Scan | ❑ CT Scan | ||
❑ MRI | D02=Hemodynamically stable? | ❑ MRI | D02=Hemodynamically stable? | ||
</div> | |||
}} | }} | ||
{{familytree | | | | | | | | |!| | | | | | | |!| |,|-|-|-|^|-|-|-|.| | | | | | | | |}} | {{familytree | | | | | | | | |!| | | | | | | |!| |,|-|-|-|^|-|-|-|.| | | | | | | | |}} | ||
{{familytree | | | | | | | | E01 | | | | | | |!| E02 | | | | | | E03 | | | | | | | |E01=Adequate imaging? | E02=No | E03=Yes}} | {{familytree | | | | | | | | E01 | | | | | | |!| E02 | | | | | | E03 | | | | | | | |E01=<div style="float: left; text-align: left; width: 18em; padding:1em;">Adequate imaging?</div> | E02=No | E03=Yes}} | ||
{{familytree | | | | | | |,|-|^|-|.| | | | | |!| |!| | | | | | | |!| | | | | | | | |}} | {{familytree | | | | | | |,|-|^|-|.| | | | | |!| |!| | | | | | | |!| | | | | | | | |}} | ||
{{familytree | | | | | | |!| | | |!| | | | | |!| F03 | | | | | | |!| | | | | | | | | F03='''Stabilize and resuscitate the patient''' <br> | {{familytree | | | | | | |!| | | |!| | | | | |!| F03 | | | | | | |!| | | | | | | | | F03=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Stabilize and resuscitate the patient''' <br> | ||
❑ Attend to the patient's ABCs (Airway, Breathing, Circulation) <br> | ❑ Attend to the patient's ABCs (Airway, Breathing, Circulation) <br> | ||
:❑ Consider endotracheal intubation if the patient's airway is compromised, has a Glasgow coma scale (GCS < 8) or profound hemodynamic instability | :❑ Consider endotracheal intubation if the patient's airway is compromised, has a Glasgow coma scale (GCS < 8) or profound hemodynamic instability | ||
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::❑ Dopamine 5 microgram/kg/minute; titrate by 5 microgram/kg/minute every 10 minutes | ::❑ Dopamine 5 microgram/kg/minute; titrate by 5 microgram/kg/minute every 10 minutes | ||
❑ Place an indwelling urethral catheter and monitor urine output <br> | ❑ Place an indwelling urethral catheter and monitor urine output <br> | ||
❑ Frequently assess mental status and check for focal neurologic deficits<br>}} | ❑ Frequently assess mental status and check for focal neurologic deficits<br></div>}} | ||
{{familytree | | | |,|-| F01 | | F02 | | | | |!| |!| | | | | | | |!| | | | | | |F01=No | F02=Yes}} | {{familytree | | | |,|-| F01 | | F02 | | | | |!| |!| | | | | | | |!| | | | | | |F01=No | F02=Yes}} | ||
{{familytree | | | G01 | | | | | |!| | | | | |!| |`|-|-|-|v|-|-|-|'| | | | | | | | |G01=Repeat imaging}} | {{familytree | | | G01 | | | | | |!| | | | | |!| |`|-|-|-|v|-|-|-|'| | | | | | | | |G01=Repeat imaging}} | ||
{{familytree | | | | | | | | | | G02 | | | | |!| | | | | G03 | | | | | | | | | | | | |G02='''AAA meets AT LEAST ONE of the following criteria for surgical or endovascular intervention?'''<br> | {{familytree | | | | | | | | | | G02 | | | | |!| | | | | G03 | | | | | | | | | | | | |G02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''AAA meets AT LEAST ONE of the following criteria for surgical or endovascular intervention?'''<br> | ||
❑ AAA > 5.5 cm, '''OR'''<br> | ❑ AAA > 5.5 cm, '''OR'''<br> | ||
❑ Rapidly expanding AAA, '''OR'''<br> | ❑ Rapidly expanding AAA, '''OR'''<br> | ||
❑ AAA plus peripheral arterial aneurysm or peripheral artery disease |G03='''Perform pre-operative work-up'''<br> | ❑ AAA plus peripheral arterial aneurysm or peripheral artery disease</div> |G03=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Perform pre-operative work-up'''<br> | ||
❑ Obtain 12 lead ECG and place the patient on a cardiac monitor <br> | ❑ Obtain 12 lead ECG and place the patient on a cardiac monitor <br> | ||
❑ Perform CT scan of the abdominal aorta and iliac arteries. (CT scan preferably '''WITH''' contrast, but may be WITHOUT contrast for patients at high risk of contrast-induced complications).<br> | ❑ Perform CT scan of the abdominal aorta and iliac arteries. (CT scan preferably '''WITH''' contrast, but may be WITHOUT contrast for patients at high risk of contrast-induced complications).<br> | ||
❑ Type and crossmatch 6 to 10 units of PRBC. FFP may also be needed in cases of massive transfusion<br> | ❑ Type and crossmatch 6 to 10 units of PRBC. FFP may also be needed in cases of massive transfusion<br> | ||
:❑ Do not administer pre-op transfusions except if patient is unconscious or has signs or myocardial infarction | :❑ Do not administer pre-op transfusions except if patient is unconscious or has signs or myocardial infarction | ||
❑ Withdraw blood for CBC, electrolytes, BUN, serum creatinine, LFTS, PT, PTT, troponin I, CK, CK-MB, CRP or ESR, and multiple blood cultures <br> | ❑ Withdraw blood for CBC, electrolytes, BUN, serum creatinine, LFTS, PT, PTT, troponin I, CK, CK-MB, CRP or ESR, and multiple blood cultures <br></div> | ||
}} | }} | ||
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| |!| | | | | |!| | | | | | | | | | | | |}} | {{familytree | | | | | | |,|-|-|-|^|-|-|-|.| |!| | | | | |!| | | | | | | | | | | | |}} | ||
{{familytree | | | | | | H01 | | | | | | H02 |!| | | | | |!| | | | | | | | | | | | |H01=No | H02=Yes}} | {{familytree | | | | | | H01 | | | | | | H02 |!| | | | | |!| | | | | | | | | | | | |H01=No | H02=Yes}} | ||
{{familytree | | | | | | |!| | | | | | | |`|-|'| | | | | H03 | | | | | | | | | | | |H03='''Pain management'''<br> | {{familytree | | | | | | |!| | | | | | | |`|-|'| | | | | H03 | | | | | | | | | | | |H03=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Pain management'''<br> | ||
❑ Assess pain severity (self-report NRS scale 0 to 10; unconscious BPS 3-12 or CPOT 0-8). Pain considered significant if NRS≥4, BPS<5, or CPOT≥3 <br> | ❑ Assess pain severity (self-report NRS scale 0 to 10; unconscious BPS 3-12 or CPOT 0-8). Pain considered significant if NRS≥4, BPS<5, or CPOT≥3 <br> | ||
❑ Administer IV opioids: Morphine 4-10 mg IV every 4 hours, infused over 4-5 minutes (dose range: 5-15 mg)<br> | ❑ Administer IV opioids: Morphine 4-10 mg IV every 4 hours, infused over 4-5 minutes (dose range: 5-15 mg)<br> | ||
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❑ Maintain patient in a conscious state<br> | ❑ Maintain patient in a conscious state<br> | ||
❑ Monitor any significant undesired drop in blood pressure as pain medications are administered}} | ❑ Monitor any significant undesired drop in blood pressure as pain medications are administered</div>}} | ||
{{familytree | | | | | | |!| | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}} | {{familytree | | | | | | |!| | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}} | ||
{{familytree | | | | | | I01 | | | | | | | | | | | | | | I02 | | | | | | | | | | | |I01='''Manage modifiable risk factors of asymptomatic AAA'''<br> | {{familytree | | | | | | I01 | | | | | | | | | | | | | | I02 | | | | | | | | | | | |I01=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Manage modifiable risk factors of asymptomatic AAA'''<br> | ||
❑ Administer aspirin 80 to 100 mg once daily if patient has no contraindication to aspirin therapy<br> | ❑ Administer aspirin 80 to 100 mg once daily if patient has no contraindication to aspirin therapy<br> | ||
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❑ Do NOT recommend intense physical activity (e.g. heavy lifting) due to increased risk of AAA rupture<br> | ❑ Do NOT recommend intense physical activity (e.g. heavy lifting) due to increased risk of AAA rupture<br> | ||
❑ Provide appropriate counseling for patients at high risk of AAA expansion and rupture | I02='''Administer antimicrobial therapy'''<br> | ❑ Provide appropriate counseling for patients at high risk of AAA expansion and rupture</div> | I02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Administer antimicrobial therapy'''<br> | ||
Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation)<br> | Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation)<br> | ||
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:❑ Ceftriaxone 2 g IV every 12 hours, '''OR''' | :❑ Ceftriaxone 2 g IV every 12 hours, '''OR''' | ||
:❑ Cefuroxime 1.5 g IV every 4 hours, '''OR''' | :❑ Cefuroxime 1.5 g IV every 4 hours, '''OR''' | ||
:❑ Piperacillin-tazobactam | :❑ Piperacillin-tazobactam <br></div> | ||
}} | }} | ||
{{familytree | | | | | | |!| | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}} | {{familytree | | | | | | |!| | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}} | ||
{{familytree | | | | | | J01 | | | | | | | | | | | | | | J02 | | | | | | | | | | | |J01='''Follow-Up'''<br> | {{familytree | | | | | | J01 | | | | | | | | | | | | | | J02 | | | | | | | | | | | |J01=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Follow-Up'''<br> | ||
❑ Schedule routine follow-up visits with abdominal ultrasound imaging at regular time intervals to monitor patients who are candidates for surgical or endovascular repair.<br> | ❑ Schedule routine follow-up visits with abdominal ultrasound imaging at regular time intervals to monitor patients who are candidates for surgical or endovascular repair.<br> | ||
❑ Do NOT schedule follow-up visits for patients who refuse either surgical or endovascular repair or who are not adequate candidates for either surgical or endovascular repair.<br> | ❑ Do NOT schedule follow-up visits for patients who refuse either surgical or endovascular repair or who are not adequate candidates for either surgical or endovascular repair.<br> | ||
Optimal interval between visits has not yet been established and is controversial. Aneurysm size should determine the frequency of follow-up ultrasound, and the following intervals may be considered based on various guidelines. |J02='''Evaluate need for further management of the following AAA complications'''<br><br> | Optimal interval between visits has not yet been established and is controversial. Aneurysm size should determine the frequency of follow-up ultrasound, and the following intervals may be considered based on various guidelines.</div> |J02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Evaluate need for further management of the following AAA complications'''<br><br> | ||
'''For patients suspected to have thromboembolism'''<br> | '''For patients suspected to have thromboembolism'''<br> | ||
❑ Obtain Duplex ultrasound of affected extremities<br> | ❑ Obtain Duplex ultrasound of affected extremities<br> | ||
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❑ Obtain CT scan with IV contrast of the abdomen and iliac arteries<br> | ❑ Obtain CT scan with IV contrast of the abdomen and iliac arteries<br> | ||
❑ Consider arteriography | ❑ Consider arteriography | ||
</div> | |||
}} | }} | ||
{{familytree | | |,|-|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.| | | |!| | | | | | | | | | | | |}} | {{familytree | | |,|-|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.| | | |!| | | | | | | | | | | | |}} | ||
{{familytree | | K01 | | K02 | | K03 | | K04 | | K05 | | K06 | | | | | | | | | | | |K01='''Aneurysm size between 5 and 5.5 cm'''<br> | {{familytree | | K01 | | K02 | | K03 | | K04 | | K05 | | K06 | | | | | | | | | | | |K01=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Aneurysm size between 5 and 5.5 cm'''<br> | ||
❑ Consider routine ultrasound every 3 months | K02='''Aneurysm size between 4.5 and 4.9 cm'''<br> | ❑ Consider routine ultrasound every 3 months</div> | K02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Aneurysm size between 4.5 and 4.9 cm'''<br> | ||
❑ Consider routine ultrasound every 12 months (1 year) | K03='''Aneurysm size between 4.0 and 4.4 cm'''<br> | ❑ Consider routine ultrasound every 12 months (1 year)</div> | K03=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Aneurysm size between 4.0 and 4.4 cm'''<br> | ||
❑ Consider routine ultrasound every 24 months (2 years) | K04='''Aneurysm size between 3.5 to 3.8 cm'''<br> | ❑ Consider routine ultrasound every 24 months (2 years)</div> | K04=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Aneurysm size between 3.5 to 3.8 cm'''<br> | ||
❑ Consider routine ultrasound every 36 months (3 years) |K05='''Aneurysm size between 2.6 to 2.9 cm'''<br> | ❑ Consider routine ultrasound every 36 months (3 years)</div> |K05=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Aneurysm size between 2.6 to 2.9 cm'''<br> | ||
❑ Consider routine ultrasound every 60 months (5 years) |K06=Evaluate patient's surgical risk}} | ❑ Consider routine ultrasound every 60 months (5 years)</div> |K06=Evaluate patient's surgical risk}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}} | ||
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{{familytree | | | | | | | | | | | | | | | | | | L01 | | | | | | L02 | | | | | | | |L01=High surgical risk| L02=Low to moderate surgical risk}} | {{familytree | | | | | | | | | | | | | | | | | | L01 | | | | | | L02 | | | | | | | |L01=High surgical risk| L02=Low to moderate surgical risk}} | ||
{{familytree | | | | | | | | | | | | | | | | |,|-|'| | | | | | | |!| | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | |,|-|'| | | | | | | |!| | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | | M01 | | | | | | | | |!| | | | | | | | |M01=Patient performed CT scan of the abdominal aorta and iliac arteries '''WITH''' contrast?}} | {{familytree | | | | | | | | | | | | | | | | M01 | | | | | | | | |!| | | | | | | | |M01=<div style="float: left; text-align: left; width: 18em; padding:1em;">Patient performed CT scan of the abdominal aorta and iliac arteries '''WITH''' contrast?</div>}} | ||
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | |}} | ||
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{{familytree | | | | | | | | | | | | | | O01 | | O02 | | | | | | |!| | | | | | | | |O01=Yes| O02=No}} | {{familytree | | | | | | | | | | | | | | O01 | | O02 | | | | | | |!| | | | | | | | |O01=Yes| O02=No}} | ||
{{familytree | | | | | | | | | | | | | | |!| | | |!| | | | | | | |!| | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | |!| | | |!| | | | | | | |!| | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | P01 | | |!| | | | | | | |!| | | | | | | | |P01=CT scan demonstrated adequate aortic anatomy and integrity suitable for endovascular procedure? }} | {{familytree | | | | | | | | | | | | | | P01 | | |!| | | | | | | |!| | | | | | | | |P01=<div style="float: left; text-align: left; width: 18em; padding:1em;">CT scan demonstrated adequate aortic anatomy and integrity suitable for endovascular procedure?</div>}} | ||
{{familytree | | | | | | | | | | | | |,|-|^|-|.| |!| | | | | | | |!| | | | | | | | |}} | {{familytree | | | | | | | | | | | | |,|-|^|-|.| |!| | | | | | | |!| | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | Q01 | | Q02 |!| | | | | | | |!| | | | | | | | |Q01=Yes |Q02=No }} | {{familytree | | | | | | | | | | | | Q01 | | Q02 |!| | | | | | | |!| | | | | | | | |Q01=Yes |Q02=No }} | ||
{{familytree | | | | | | | | | | | | |!| | | |`|-|^|-|-|-|v|-|-|-|'| | | | | | | | |}} | {{familytree | | | | | | | | | | | | |!| | | |`|-|^|-|-|-|v|-|-|-|'| | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | R01 | | | | | | | | R02 | | | | | | | | | | | |R01='''Consider any of the following:'''<br> | {{familytree | | | | | | | | | | | | R01 | | | | | | | | R02 | | | | | | | | | | | |R01=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Consider any of the following:'''<br> | ||
❑ Endovascular repair, '''OR''' | ❑ Endovascular repair, '''OR''' | ||
❑ Open AAA repair |R02=Open AAA Repair | ❑ Open AAA repair |R02=Open AAA Repair</div>}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 13:04, 9 April 2015
Overview
Classification
Abdominal aortic aneurysms may be classified based on the size of the aneurysm:
- Small aneurysm: Diameter < 4.0 cm
- Medium aneurysm: Diameter between 4.0 and 5.5 cm
- Large aneurysm: Diameter ≥ 5.5 cm
- Very large aneurysm: Diameter ≥ 6.0 cm
Abdominal aortic aneurysms may also be classified based on the rate of aneurysm expansion:
- Non-rapidly expanding aneurysm: Diameter increase of ≤ 0.5 cm within 6 months OR ≤ 1.0 cm within 12 months
- Rapidly expanding aneurysm: Diameter increase of > 0.5 cm within 6 months OR > 1.0 cm within 12 months
Causes
Life Threatening Causes
- Ruptured AAA
- Infected (mycotic) aneurysm
- Inflammatory AAA
- Aortovenous fistula
- Aortoenteric fistula
- Lower extremity thromboembolism
Risk Factors for Development of AAA
- Old age 50 > years
- Greater height
- Male gender
- Caucasian race
- Smoking
- History of CAD and atherosclerotic cardiovascular disease
- History of hypertension
- Dyslipidemia
- Family history of AAA
- Personal history of peripheral artery aneurysms
Risk Factors for Rapid Expansion or Rupture of AAA
- Female gender
- Advanced age > 50 years
- Smoking
- Advanced atherosclerosis
- History of prior stroke
- Hypertension
- Transplantation (cardiac or renal)
- Known reduced FEV1 (obstructive pulmonary disease)
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate surgical intervention. Boxes in red signify that an urgent management is needed.
Identify cardinal findings that increase the pre-test probability of abdominal aortic aneurysm (AAA) rupture and development of complications ❑ Known large AAA > 5.5 cm
❑ Pulsating abdominal mass
| |||||||||||||||||||||||||||||||||||||||
Rule out life threatening alternative diagnoses: (suggestive findings: vomiting, subcutaneous emphysema) | |||||||||||||||||||||||||||||||||||||||
Stabilize and resuscitate the patient ❑ Attend to the patient's ABCs (Airway, Breathing, Circulation)
❑ Obtain 12 lead ECG and place the patient on a cardiac monitor
❑ Withdraw blood for CBC, electrolytes, BUN, serum creatinine, LFTS, PT, PTT, troponin I, CK, CK-MB, CRP or ESR, and multiple blood cultures
❑ Maintain patient in a conscious state | |||||||||||||||||||||||||||||||||||||||
Patient hemodynamically unstable despite resuscitation? ❑ Hypotension (SBP < 90 mm Hg) despite resuscitation ❑ Tachycardia (HR > 100 bpm) despite resuscitation | |||||||||||||||||||||||||||||||||||||||
Yes. Patient is still hemodynamically unstable despite resuscitation. | No. Patient is hemodynamically stable following resuscitation | ||||||||||||||||||||||||||||||||||||||
Is the patient known to have an AAA? | Can patient have CT scan with contrast? | ||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ||||||||||||||||||||||||||||||||||||
❑ Proceed to operating room without further work-up | ❑ Obtain focused bedside ultrasound | ❑ Obtain CT scan with IV contrast of abdominal aorta and iliac arteries | ❑ Obtain CT scan without IV contrast of abdominal aorta and iliac arteries | ||||||||||||||||||||||||||||||||||||
AAA confirmed on imaging? | |||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||
Consider alternative diagnoses | |||||||||||||||||||||||||||||||||||||||
Evaluate need for further management of the following AAA complications | |||||||||||||||||||||||||||||||||||||||
Administer antimicrobial therapy Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation)
| |||||||||||||||||||||||||||||||||||||||
Proceed to further management | |||||||||||||||||||||||||||||||||||||||
Diagnosis
Treatment
Shown below is an algorithm summarizing the management of abdominal aortic aneurysm.
Confirmed AAA | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Symptoms present? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑Perform imaging using ANY of the following imaging modalities for the abdominal aorta and iliac arteries: ❑ Ultrasound ❑ CT Scan ❑ MRI | Hemodynamically stable? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adequate imaging? | No | Yes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stabilize and resuscitate the patient ❑ Attend to the patient's ABCs (Airway, Breathing, Circulation)
❑ Place an indwelling urethral catheter and monitor urine output | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Repeat imaging | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
AAA meets AT LEAST ONE of the following criteria for surgical or endovascular intervention? ❑ AAA > 5.5 cm, OR | Perform pre-operative work-up ❑ Obtain 12 lead ECG and place the patient on a cardiac monitor
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No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pain management ❑ Assess pain severity (self-report NRS scale 0 to 10; unconscious BPS 3-12 or CPOT 0-8). Pain considered significant if NRS≥4, BPS<5, or CPOT≥3
❑ Maintain patient in a conscious state | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Manage modifiable risk factors of asymptomatic AAA ❑ Administer aspirin 80 to 100 mg once daily if patient has no contraindication to aspirin therapy ❑ Administer statin therapy (e.g. simvastatin 40 mg once daily) if patient has no contraindication to statin therapy ❑ Manage hypertension based on guidelines for the management of hypertension (There are currently no recommended antihypertensive pharmacologic therapies for the management of AAA) ❑ Recommend smoking cessation ❑ Recommend moderate physical activity at least 4 times per week (e.g. running, swimming, golfing) ❑ Do NOT recommend intense physical activity (e.g. heavy lifting) due to increased risk of AAA rupture | Administer antimicrobial therapy Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation)
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Follow-Up ❑ Schedule routine follow-up visits with abdominal ultrasound imaging at regular time intervals to monitor patients who are candidates for surgical or endovascular repair. | Evaluate need for further management of the following AAA complications For patients suspected to have thromboembolism | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Aneurysm size between 5 and 5.5 cm ❑ Consider routine ultrasound every 3 months | Aneurysm size between 4.5 and 4.9 cm ❑ Consider routine ultrasound every 12 months (1 year) | Aneurysm size between 4.0 and 4.4 cm ❑ Consider routine ultrasound every 24 months (2 years) | Aneurysm size between 3.5 to 3.8 cm ❑ Consider routine ultrasound every 36 months (3 years) | Aneurysm size between 2.6 to 2.9 cm ❑ Consider routine ultrasound every 60 months (5 years) | Evaluate patient's surgical risk | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
High surgical risk | Low to moderate surgical risk | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patient performed CT scan of the abdominal aorta and iliac arteries WITH contrast? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CT scan demonstrated adequate aortic anatomy and integrity suitable for endovascular procedure? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider any of the following: ❑ Endovascular repair, OR ❑ Open AAA repair | Open AAA Repair | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Screening
Screening for AAA is currently recommended only once in the following patient groups:
- Men between the age of 65 and 75 years and who have ever smoked
- Men aged 60 years or older with a sibling or a parent with abdominal aortic aneurysm
There are currently no recommendations to screen AAA in women, but women are at increased risk of AAA expansion or rupture. Some experts recommend one-time screening in women with risk factors of developing AAA (such as smoking or positive family history)