Abdominal
aortic aneurysm
The right clinical information, right where it's needed
Last updated: Nov 13, 2017
Table of Contents
Summary
3
Basics
4
Definition
4
Epidemiology
4
Aetiology
4
Pathophysiology
4
Classification
5
Prevention
Screening
Diagnosis
6
6
7
Case history
7
Step-by-step diagnostic approach
7
Risk factors
8
History & examination factors
10
Diagnostic tests
10
Differential diagnosis
12
Treatment
15
Step-by-step treatment approach
15
Treatment details overview
27
Treatment options
29
Emerging
35
Follow up
36
Recommendations
36
Complications
36
Prognosis
37
Guidelines
38
Diagnostic guidelines
38
Treatment guidelines
38
References
40
Images
52
Disclaimer
59
Summary
◊ Typically asymptomatic and discovered incidentally, but abdominal pain and back pain are the most
common symptomatic complaints.
◊ Diagnosis relies on imaging. Ultrasound remains the definitive test for initial diagnosis and screening.
CT scan is typically required for preoperative planning.
◊ Repair is deferred until the theoretical risk of rupture exceeds the estimated risk of operative
mortality. Repair is indicated in patients with symptomatic AAA or asymptomatic AAA with a diameter
exceeding 5.5 cm in men or 5.0 cm in women.
◊ Complications of treatment include cardiac and pulmonary events, mesenteric ischaemia, renal
failure, bleeding, wound and graft infection, spinal cord ischaemia/paraplegia, embolisation/limb
ischaemia, and late graft complications (i.e., aorto-enteric fistula and aortic pseudoaneurysm).
Endovascular repair offers the additional potential complications of endoleak, graft occlusion, and
graft migration with aortic neck expansion.
Abdominal aortic aneurysm
Basics
BASICS
Definition
Abdominal aorta aneurysm (AAA) is a permanent pathological dilation of the aorta with a diameter >1.5
times the expected anteroposterior (AP) diameter of that segment, given the patient's gender and body
size.[1] [2]
[Fig-1]
This is approximately 3 cm in most people. More than 90% of aneurysms originate below the renal
arteries.[3]
Epidemiology
In the UK, Denmark, and Australia, using randomised controlled trials, screening for AAA was carried out. In
total, there were 128,891 men and 9342 women. A Cochrane review of the data (2007) found that, between
the age of 65 and 79 years, 5% to 10% of men have AAA.[8] Epidemiology varies by region and with a
number of other demographic factors. The general prevalence of 2.9 cm to 4.9 cm AAAs range from 1.3% for
men aged 45 to 54 years, to 12.5% for men 75 to 84 years of age (0% and 5.2% for women, respectively).[3]
The prevalence of aneurysms among men increases by about 6% per decade.[7] In 2004 AAA was the 14th
leading cause of death for the 60- to 85-year-old age group in the US, and there were 13,753 deaths from
aortic aneurysm and dissection combined in 2004.[9] [10]Prevalence among men is 4 to 6 times higher than
in women.[1] [11]
Aetiology
The aetiology is multi-factorial. Traditionally, arterial aneurysms were thought to arise from atherosclerotic
disease, and certainly intimal atherosclerosis reliably accompanies AAA.[12] More recent data suggest
that altered tissue metalloproteinases may diminish the integrity of the arterial wall.[5] The underlying
pathophysiology remains constant with aortic elastic medial degeneration and mild cystic medial necrosis
resulting in aortic dilation and aneurysm formation.
Pathophysiology
The pathogenesis is complex and multi-factorial. Histologically there is obliteration of collagen and elastin
in the media and adventitia, smooth muscle cell loss with resulting tapering of the medial wall, infiltration
of lymphocytes and macrophages, and neovascularisation.[12] There are 4 mechanisms relevant to AAA
development:[13]
• Proteolytic degradation of aortic wall connective tissue: matrix metalloproteinases (MMPs) and
other proteases are derived from macrophages and aortic smooth muscle cells and secreted into
the extracellular matrix. Disproportionate proteolytic enzyme activity in the aortic wall may promote
deterioration of structural matrix proteins (e.g., elastin and collagen).[3] Increased expression of
collagenases MMP-1 and -13 and elastases MMP-2, -9, and -12 has been demonstrated in human
AAAs.[14] [15] [16] [17]
• Inflammation and immune responses: an extensive transmural infiltration by macrophages and
lymphocytes is present on aneurysm histology and these cells may release a cascade of cytokines
that subsequently activate many proteases.[12] Additionally, deposition of IgG into the aortic wall
4
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Abdominal aortic aneurysm
Basics
Classification
Types of AAA
Specific types of AAA are:[4] [5]
• Congenital: while medial degeneration occurs naturally with age, it is accelerated in patients with
bicuspid aortic valves and Marfan's syndrome.
• Infectious: infection of the aortic wall (mycotic aneurysm) is a rare aetiology. Staphylococcus and
Salmonella are the most common pathogens. Chlamydia pneumoniae has been postulated as an
infectious aetiology for conventional aneurysms.
• Inflammatory: the aetiology of inflammatory AAAs remains controversial. This variant is characterised
by an abnormal accumulation of macrophages and cytokines in diseased tissue. Pathologically there is
perianeurysmal fibrosis, thickened walls, and dense adhesions.
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5
BASICS
supports the hypothesis that AAA formation may be an autoimmune response. There is currently
interest in the role of reactive oxygen species and antioxidants in AAA formation.[14] [18] [19] [20] [21]
• Biomechanical wall stress: elastin levels and the elastin-collagen ratio decrease progressively distal
down the aorta. Diminished elastin is associated with aortic dilation, and collagen degradation
predisposes to rupture.[11] Additionally, data support increased MMP-9 expression and activity,
disordered flow and an increase in wall tension, and relative tissue hypoxia in the distal aorta (i.e.,
infra-renal).[14] [22] [23]
• Molecular genetics: while there is no single genetic defect or polymorphism responsible, there is
familial clustering, a common HLA subtype, and several altered gene expressions and polymorphisms
linked, suggesting a genetic role in pathogenesis.[14] [24] [25]
Abdominal aortic aneurysm
Prevention
Screening
PREVENTION
Screening may reduce the incidence of aortic rupture, especially if applied to high-risk groups.[8] [60] [61]
[62]Current recommendations include: [47]
• One-time ultrasound screening for AAA is recommended for all men aged ≥65 years. Screening men
as early as 55 years is appropriate for those with a family history of AAA.
• Re-screening patients for AAA is not recommended if an initial ultrasound scan performed on patients
aged ≥65 years demonstrates an aortic diameter of 2.6 cm.
• Surveillance imaging at 12-month intervals is recommended for patients with an AAA of 3.5 to 4.4 cm
in maximum diameter.
• Surveillance imaging at 6-month intervals is recommended for those patients with an AAA between 4.5
and 5.4 cm in maximum diameter.
• Follow-up imaging at 3 years is recommended for those patients with an AAA between 3.0 and 3.4 cm
in maximum diameter.
• Follow-up imaging at 5-year intervals is recommended for patients whose maximum aortic diameter is
between 2.6 and 2.9 cm.
These recommendations are based on a meta-analysis of published data regarding the use of screening
programmes to detect AAA compiled and summarised by the United States Preventative Services Task
Force (USPSTF), several randomised trials, and the concept that screening for AAA and surgical repair of
large AAAs (≥5.5 cm) in men aged 65 to 75 years who have ever smoked leads to decreased AAA-specific
mortality.[47] [49] [63] [64] [65] [66] [67] [68] [69] [70] [71]
While the USPSTF argues against screening in women, some authors argue that in certain subgroups of
women at increased risk of AAA (i.e., age ≥65 years with a positive history of smoking or family history of
AAA) screening should be considered with one-time ultrasound.[1] [44] [47] [63] [72]
6
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Abdominal aortic aneurysm
Diagnosis
Case history
Case history #1
A 70-year-old man presents to his primary care physician for a health maintenance examination. He has
been feeling well and in his usual state of good health. His medical history is notable for mild HTN and
he has a 100-pack-year tobacco history. On clinical examination, there is a palpable pulsatile abdominal
mass.
Case history #2
A 55-year-old man with a history of HTN (well controlled with medication) and tobacco use presents to his
primary care physician with a 2-day history of constant and gnawing hypogastric pain. The pain has been
steadily worsening in intensity. He believes the pain radiates to his lower back and both groins at times.
While he cannot identify any aggravating factors (such as movement), he feels the pain improves with his
knees flexed. There is a palpable pulsatile mass just left of midline below the umbilicus. He is immediately
referred for definitive management, but during transfer becomes hypotensive and unresponsive.
Other presentations
The triad of abdominal pain, weight loss, and elevated ESR suggests inflammatory AAA.[5] A tender,
palpable pulsatile mass on examination and elevated CRP may also be present. Abdominal or back pain
with fever is suggestive of mycotic or infectious AAA. Typically there is history of arterial trauma, IV drug
abuse, local or concurrent infection, bacterial endocarditis, or impaired immunity. Osteomyelitis of the
thoracic or lumbar spine may develop. Anaemia, leukocytosis, and positive blood cultures are common.[6]
Diagnosis may be aided by complications of unruptured aneurysms, including distal embolisation, acute
thrombosis, or symptoms caused by ureterohydronephrosis.[7]
DIAGNOSIS
Step-by-step diagnostic approach
Patients most commonly lack any symptoms and their aneurysm is noted on physical examination or
radiographic studies performed for other reasons.
History
Typical symptoms include abdominal, back, and groin pain. Medical history is directed towards risk
factors:
• Development (i.e., hyperlipidaemia, connective tissue disorder, COPD, and HTN)[1] [3] [7] [11] [26]
[41] [42]
• Expansion (i.e., previous cardiac or renal transplant, previous stroke, advanced age (>70 years),
and severe cardiac disease)[44] [45]
• Rupture (i.e., female sex, previous cardiac or renal transplant, HTN).[7] [43] [44] [46]
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7
Abdominal aortic aneurysm
Diagnosis
A history of cigarette smoking increases a patient's risk of AAA development, expansion, and rupture.[7]
[26] [27] [28] [44] A history of previous abdominal surgery or previous endovascular aortic aneurysm
repair can be elicited as well as family history of AAA.
Physical examination
The abdomen can be palpated for a pulsatile abdominal mass and abdominal tenderness. Physical
examination should include an assessment of femoral and popliteal arteries in all patients with a
suspected AAA as an AAA is present in 62% of patients with a popliteal aneurysm and in 85% of patients
with a femoral artery aneurysm.[44] [45] [47]
Aneurysm palpation on clinical examination has only been shown to be sensitive in thin patients and
those with AAA >5 cm with an overall sensitivity and specificity of 68% and 75%, respectively.[1] [48]
Ruptured aneurysm presents with the triad of abdominal and/or back pain, pulsatile abdominal mass, and
hypotension.
The presence of fever may increase suspicion for infectious AAA in the appropriate clinical setting.
Key tests
Ultrasonography is the initial method of choice for AAA detection (sensitivity and specificity of 95% and
nearly 100%, respectively). Once the diagnosis is made, further imaging with CT, MRI, or magnetic
resonance angiography (MRA) is used for anatomical mapping to assist with operative planning (open or
endovascular).[7] [49]
Elevated ESR and CRP support a diagnosis of possible inflammatory AAA. Leukocytosis and a relative
anaemia on FBC with positive blood cultures are indicative of infectious AAA.
DIAGNOSIS
Predictors of rupture risk including AAA expansion rate, increase in intraluminal thrombus thickness, wall
stiffness, wall tension, and peak AAA wall stress.[47] [50]
Risk factors
Strong
cigaret te smoking
• This is the risk factor most strongly associated.[1] [7] [11] [26] [27]
• Active cigarette smoking is independently associated with histological high-grade tissue
inflammation.[28]
• The duration of smoking is significantly associated with an increased risk in a linear dose-response
relationship. Each year of smoking increases the relative risk by 4%.[27]
hereditary/family history
• Studies support a familial aggregation of and genetic predisposition to AAA.[1] [7] [25] [29] [30] [31]
[32] [33] [34] [35]
• The age- and sex-adjusted relative risk to a first-degree relative of an AAA patient is 11.6% and a
history of AAA in a parent confers the same excess risk.[32]
8
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Abdominal aortic aneurysm
Diagnosis
• The overall prevalence of AAA in siblings of AAA patients is 8 times that observed among control
cohort.[33] First-degree relatives have been shown to have an AAA in 15% to 28% of cases.[3] [34]
[35]
increased age
• Prevalence increases with age.[1] [11]
• Most frequently diagnosed in men >55 years of age and rupture rarely occurs before 65 years of age.
• AAA is discovered approximately 10 years later in women.[7] [36] [37]
male sex (prevalence)
• AAAs are 4 to 6 times more prevalent in men than women.[1] [7] [11]
female sex (rupture)
• Female sex increases risk of rupture.[34] [38]
congenital/connective tissue disorders
• Aortic degeneration is accelerated in patients with bicuspid aortic valves, Marfan's syndrome, and
during pregnancy.[39] [40] [41]
• Marfan's syndrome specifically is associated with cystic medial necrosis of the aorta secondary to an
autosomal dominant anomaly in fibrillin type 1, a structural protein that directs and orients elastin in
the developing aorta.[39] [40] As a result, the mature aorta demonstrates abnormal elastic properties,
progressive stiffening, and dilation.[41]
Weak
hyperlipidaemia
COPD
• This is attributed to tobacco-induced elastin degradation.[3] [7]
• Studies suggest that the association between reduced respiratory function and AAA may be due to the
activation of inflammation and haemostasis in response to injury.[42]
atherosclerosis (i.e., CAD, peripheral arterial occlusive disease)
• CAD is an independent associated risk factor.[1] [26]
HTN
• HTN is a weak independent risk factor.[1] [7] [11]
• There is a relation between systolic BP and AAA in women and an association with ever-use
antihypertensive medication and AAA risk for both sexes.[11] [37]
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9
DIAGNOSIS
• Lipoproteins are elevated in patients with AAA independent of cardiovascular risk factors and extent of
atherosclerosis.[3] [7]
• AAA patients have significantly lower levels of apolipoprotein AI and HDL cholesterol than matched
controls with aorto-iliac occlusive disease.[1] [3]
• High serum total cholesterol is a relatively weak risk factor for AAA, whereas high HDL cholesterol was
strongly associated with a low risk of AAA.[11] [37]
Diagnosis
Abdominal aortic aneurysm
increased height
• Increased height is an independent associated risk factor, although after adjustment for age and sex
the association was no longer significant.[1] [26] [43]
central obesity
• While obesity is generally not considered a risk factor, one study of more than 12,000 men
demonstrated an independent association between central obesity and AAA.[37]
non-diabetic
• Diabetes is negatively associated with AAA.[26] [34] [37]
History & examination factors
Key diagnostic factors
presence of risk factors (common)
• Key risk factors include cigarette smoking, family history, increased age, male sex for prevalence and
female sex for rupture, and congenital/connective tissue disorders.
palpable pulsatile abdominal mass (uncommon)
• Aneurysm palpation on clinical examination has been shown to be sensitive only in thin patients and
those with AAA >5 cm (sensitivity and specificity of 68% and 75%, respectively).[1] [48]
Other diagnostic factors
abdominal, back, or groin pain (uncommon)
DIAGNOSIS
• However, patients are usually asymptomatic and their aneurysm is detected incidentally.
hypotension (uncommon)
• Patients with ruptured aneurysm present with the triad of abdominal and/or back pain, pulsatile
abdominal mass and hypotension.
Diagnostic tests
1st test to order
Test
Result
abdominal ultrasound
aortic dilation of >1.5
times the expected
anterior-posterior
diameter of that segment,
given the patient's sex
and body size; this is
approximately 3 cm in
most individuals
• Definitive test (sensitivity and specificity of 92% to 99% and nearly
100%, respectively).[1] [2] [48] [8]
• The ultrasound is performed perpendicular to the aortic axis as
oblique views may overestimate the true aortic diameter.[2]
• Intra-observer correlation may be better near the aortic bifurcation
than in the proximal infrarenal aorta.[49]
• Unfortunately, ultrasound offers little utility in imaging aneurysms
close to the origins of, or proximal to, the renal arteries.[51] [52]
10
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Diagnosis
Abdominal aortic aneurysm
Other tests to consider
Test
Result
ESR/CRP
elevated
• Suggests inflammatory AAA.
FBC
leukocytosis, anaemia
• Leukocytosis and a relative anaemia on FBC with positive blood
cultures are indicative of infectious AAA.
blood cultures
positive
• Leukocytosis and a relative anaemia on FBC with positive blood
cultures are indicative of infectious AAA.
CT
• May demonstrate blood within the thrombus (crescent sign), low
thrombus-to-lumen ratio retroperitoneal haematoma, discontinuity of
the aortic wall, or extravasation of contrast into the peritoneal cavity,
which are all signs of impending rupture.[7] [53]
• Also useful in diagnosing aortic aneurysms close to the origins of, or
proximal to, the renal arteries.[52] [53]
MRI/MRA
• Preoperative study of choice for operative strategy if a patient has an
iodinated contrast allergy.
aortography
• Adjunctive modality for preoperative planning.
aaortic dilation of >1.5
times the expected
anterior-posterior
diameter of that segment,
given the patient's sex
and body size; this is
approximately 3 cm in
most individuals
aortic dilation of >1.5
times the expected
anterior-posterior
diameter of that segment,
given the patient's sex
and body size; this is
approximately 3 cm in
most people
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11
DIAGNOSIS
Contrast aortography
may aid with preoperative
planning and sizing for
those patients unable
to undergo CT imaging.
Additionally, it may be
used to diagnose and
treat arterial occlusive
disease prior to open AAA
repair or endovascular
repair (EVAR) (i.e., renal or
mesenteric disease)
Diagnosis
Abdominal aortic aneurysm
Differential diagnosis
Condition
Diverticulitis
Renal colic
DIAGNOSIS
Irritable bowel syndrome
(IBS)
12
Differentiating signs / Differentiating tests
symptoms
• Obstipation; abdominal
pain is more common and
typically localises to the left
lower quadrant.
• No pulsatile abdominal mass
on clinical examination.
Instead, abdominal or
perirectal "fullness" may
be appreciated. Fever is
possible.[54]
•
• Severe abdominal pain
that starts in the flank and
radiates anteriorly to the
groin.
• Associated with nausea,
emesis, haematuria, dysuria,
and urinary frequency or
urgency.[55]
•
• Intermittent abdominal
discomfort with flares lasting
2 to 4 days.
• Associated symptoms
may include bloating, stool
frequency, and abnormal
defecation.
• Women aged 20 to 40 years
are affected more often than
men.
• On examination, most
patients appear anxious,
although general
examination is usually
normal. There may be
poorly localised abdominal
tenderness to palpation.[56]
•
•
•
•
Stool guaiac testing may be
trace positive.
Leukocytosis may be
present.
CT scan will demonstrate
a normal-calibre aorta
and possibly diverticula,
inflammation of the pericolic
fat or other tissues, bowelwall thickness >4 mm, or a
peridiverticular abscess.[54]
Urinalysis positive for blood
and may demonstrate
crystals and/or evidence of
infection.
Ultrasound and CT scan
will demonstrate a normalcalibre aorta and possibly
ureteral or renal stones.[55]
Imaging modalities are
often inconclusive, but will
demonstrate a normalcalibre aorta.
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Diagnosis
Abdominal aortic aneurysm
Condition
Inflammatory bowel
disease
Differentiating signs / Differentiating tests
symptoms
• Abdominal pain is often
"crampy" and left-sided.
Patients typically suffer
from diarrhoea (bloody and
non-bloody), urgency of
defecation, and tenesmus.
• Extra-intestinal
manifestations are common
in Crohn's disease.
• Abdominal examination
may demonstrate abnormal
bowel sounds, detection
of an abdominal mass,
and pain on palpation.
Mucocutaneous lesions may
be visible. Peri-anal fistulae,
fissures, or abscesses
may be present on rectal
examination.[57]
•
•
• Pain is typically periumbilical
with localisation to the right
lower quadrant.
• Associated nausea, emesis,
and anorexia are common.
• Patients are classically
febrile with tenderness in
the right lower quadrant
or rebound tenderness on
abdominal examination.
•
Ovarian torsion
• Women suffer sudden,
continuous, non-specific
pain in the lower abdomen;
nausea and emesis are
common. Patients may
demonstrate fever on clinical
examination and an adnexal
mass may be palpable.[58]
•
Leukocytosis may be
present. Ultrasound will
demonstrate a normal calibre
aorta and possible reduced
or absence of adnexal
vascular flow.[58]
GI haemorrhage
• Patients presenting with
haemorrhagic shock may
mimic aortic rupture. A
history of previous GI bleed,
haematemesis, melaena, or
bright red blood per rectum
is common.
• Historical risk factors for GI
malignancy or peptic ulcer
disease may be elicited.
• On rectal examination gross
blood may be visible or
coffee ground haematemesis
may be returned with
nasogastric tube placement.
•
Stool is likely to be guaiac
positive.
Endoscopic evaluation may
demonstrate the luminal
bleeding source along with
mucosal ulcerations, polyps,
or tumour.
Radiographical imaging with
ultrasound or CT scan will
demonstrate a normal calibre
aorta.
Appendicitis
•
•
•
Leukocytosis and sterile
pyuria on urinalysis is
common.
Imaging with ultrasound or
CT scan will demonstrate
a normal-calibre aorta with
an inflamed appendix or
evidence of perforation.
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13
DIAGNOSIS
•
Anaemia is common.
Radiographical imaging
(i.e., ultrasound or CT scan)
will demonstrate a normalcalibre aorta.
Endoscopic evaluation
with biopsy shows typical
lesions of ulcerative colitis or
Crohn's disease.[57]
Diagnosis
Abdominal aortic aneurysm
Condition
• Acute embolic or thrombotic
occlusion of the splanchnic
vessels results in a marked
disparity between acute
excruciating mid-abdominal
pain and a paucity of early
physical findings.
• Patients typically suffer
unremitting, intense midabdominal pain with nausea
and vomiting that might be
accompanied by explosive
diarrhoea.
• Most splanchnic
artery aneurysms are
asymptomatic until
rupture.[59]
•
•
•
Leukocytosis,
haemoconcentration,
and systemic acidosis
are common with acute
splanchnic vessel occlusion.
Elevated levels of serum
amylase, inorganic
phosphorous, creatinine
phosphokinase, and
alkaline phosphatase may
accompany frank bowel
infarction.
Angiography is diagnostic
and potentially therapeutic
in the case of vascular
occlusion.
Ultrasound and CT scan
will demonstrate a normalcalibre aorta and will
diagnose any splanchnic
artery aneurysms.[59]
DIAGNOSIS
Splanchnic artery
aneurysms/acute
occlusion
Differentiating signs / Differentiating tests
symptoms
14
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Abdominal aortic aneurysm
Treatment
Step-by-step treatment approach
Patients presenting with a ruptured aneurysm require emergent repair, and for patients with symptomatic
aortic aneurysms, repair is indicated regardless of diameter.[73] For AAA detected as an incidental finding,
repair is deferred until the theoretical risk of rupture exceeds the estimated risk of operative mortality.
Generally, repair is indicated in patients with large asymptomatic AAA (e.g., with a diameter exceeding 5.5
cm in men or 5.0 cm in women, in the US), although treatment decisions based on greater size may differ in
other countries (e.g., UK).[1] [74] [75] [76] [77] [78]
Types of repair
Open repair:
• The conventional open repair ensues through a retroperitoneal (RP) or transperitoneal incision.
With proximal and distal aortic control obtained, the aneurysm is opened, back-bleeding branch
arteries are ligated, and a prosthetic graft is sutured from normal proximal aorta to normal distal
aorta (or iliac segments). Once flow is restored to the bilateral iliac arteries the aneurysm sac is
closed over the graft.[79]
• Although advocates of an RP approach claim various physiological benefits, including reductions
in fluid losses, cardiac stress, postoperative pulmonary complications, and severity of ileus,
randomised prospective studies have generated conflicting results. A retroperitoneal approach
should be considered for patients in which aneurysmal disease extends to the juxtarenal and/or
visceral aortic segment, or in the presence of an inflammatory aneurysm, horseshoe kidney, or
hostile abdomen.[47] [80] [81]
• Straight tube grafts are recommended for repair in the absence of significant disease of the iliac
arteries.[47]
• The proximal aortic anastomosis should be performed as close to the renal arteries as possible.[47]
It is recommended that all portions of an aortic graft should be excluded from direct contact with the
intestinal contents of the peritoneal cavity.[47]
• Re-implantation of a patent inferior mesenteric artery (IMA) should be considered under
circumstances that suggest an increased risk of colonic ischaemia (i.e., associated coeliac or
superior mesenteric artery occlusive disease, an enlarged meandering mesenteric artery, a history
of prior colon resection, inability to preserve hypogastric perfusion, substantial blood loss or
intraoperative hypotension, poor IMA backbleeding when graft open, poor Doppler flow in colonic
vessels, or should the colon appear ischaemic).[47] [82]
• This repair is effective and durable; 5-year survival rates after intact aneurysm repair average 60%
to 75%.[83]
• Complications include cardiac and pulmonary events, mesenteric ischaemia, renal failure, bleeding,
wound and graft infection, spinal cord ischaemia/paraplegia, embolisation/limb ischaemia, and late
graft complications (i.e., aorto-enteric fistula and aortic pseudoaneurysm).[1] [84]
• The operative mortality associated with open repair averages 2% to 7%; this has prompted a
movement towards less-invasive technique and endovascular AAA repair.[85] [86]
• EVAR is progressively replacing open repair for the treatment of infrarenal AAA, and now accounts
for more than 50% of all AAA repairs in the US.[47]
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15
TREATMENT
Endovascular repair (EVAR):
Abdominal aortic aneurysm
Treatment
• Data suggest that in patients with large AAAs (ranging from 5 to 5.5 cm) undergoing elective repair,
EVAR is equivalent to open repair in terms of overall survival, although the rate of secondary
interventions is higher for EVAR.[87] [88]EVAR also reduces AAA-related mortality (but not longerterm overall survival) in patients unsuitable for open repair.[89]
• EVAR involves the transfemoral endoluminal delivery of a covered stent graft into the aorta, thus
sealing off the aneurysm wall from systemic pressures, preventing rupture, and allowing for sac
shrinkage.
[Fig-2]
[Fig-3]
• Additional complications may include endoleak, graft occlusion, and graft migration with aortic neck
expansion.[83]
• Studies support that EVAR offers patients an early perioperative mortality benefit (0% to 1.7%) with
decreased hospital length of stay and blood product utilisation.[1] [90] [91] [92]The advantage is
lost with longer follow-up, and no advantage with respect to all-cause mortality or quality of life has
been demonstrated.[1] [93] [94] [95] [96] [97]
• Late re-interventions related to AAA are more common after EVAR but are balanced by an increase
in laparotomy-related re-interventions (i.e., incisional hernia repair) and hospitalisations after open
surgery.[98]
• Multivariate meta-regression analysis showed that rates of operative mortality, postoperative
rupture, and total number of endoleaks have all fallen significantly, demonstrating a low mortality
and a gradual reduction in vascular morbidity and mortality associated with endovascular repair
since it was first introduced.[99]
• As an adjunct to EVAR, bilateral hypogastric artery occlusion may be acceptable in certain
anatomical situations for patients at high risk for open surgical repair. Buttock claudication and
erectile dysfunction may occur in up to 40% of patients after unilateral embolisation - these
symptoms may persist in 11% to 13% of patients following bilateral occlusion.[47] [100] [101]
Internal iliac artery revascularisation techniques, involving specialised iliac branch devices, have
high technical success rates and are associated with low morbidity (e.g., buttock claudication rate
of 4.1%).[102]
TREATMENT
Treatment of co-existing cardiac disease
While a substantial number of patients suffering from AAA also have underlying coronary artery disease,
non-invasive stress testing should be considered for patients with a history of ≥3 clinical risk factors (i.e.,
CAD, congestive heart failure, stroke, diabetes mellitus, chronic renal insufficiency) and an unknown
or poor functional capacity (MET <4) that are undergoing endovascular repair (EVAR) or open surgical
repair, if it will change management. While routine coronary revascularisation by coronary artery bypass
grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) prior to elective vascular
surgery in patients with stable cardiac symptoms does not appear to significantly alter the risk of
postoperative MI or death or long-term outcome, coronary revascularisation is indicated for those patients
who present with acute ST elevation MI, unstable angina, or stable angina with left main coronary artery
or 3-vessel disease, as well as those patients with 2-vessel disease that includes the proximal left anterior
descending artery and either ischaemia on non-invasive testing or an ejection fraction <0.5.[47]
Perioperative management
Regarding blood transfusion:[47]
16
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Abdominal aortic aneurysm
Treatment
• Preoperative autologous blood donation may be beneficial for patients undergoing open aneurysm
repair.
• Cell salvage or an ultrafiltration device is recommended if large blood loss is anticipated or the risk
of disease transmission from banked blood is considered high.
• Intraoperative blood transfusion is recommended for a haematocrit <30% in the presence of
ongoing blood loss.
• If the intraoperative haematocrit is <30% and blood loss is ongoing, consider use of FFP and
platelets in a ratio with packed blood cells of 1:1:1.
Pulmonary artery catheters should not be used routinely in aortic surgery, unless there is a high risk for a
major haemodynamic disturbance.[47] Central venous access is recommended for all patients undergoing
open aneurysm repair.[47] DVT prophylaxis consisting of intermittent pneumatic compression and early
ambulation are recommended for all patients undergoing open repair or EVAR.[47] [103]
Preoperative cardiovascular risk reduction:
• Preoperative beta-blockade may be reasonable in patients with intermediate- or high-risk
myocardial ischaemia, and those with 3 or more RCRI (revised cardiac risk index) risk factors
(e.g., diabetes mellitus, heart failure, CAD, renal insufficiency, stroke). When indicated, betablocker therapy should be started more than 1 day before surgery.[104] [105] A systematic review
found that perioperative beta-blockade started within 1 day or less before non-cardiac surgery
prevented non-fatal myocardial infarction, but increased the risk of stroke, death, hypotension, and
bradycardia.[105]
• Perioperative statin use reduces cardiovascular events during non-cardiac surgery.[104]
• A large, multi-centre study of patients undergoing non-cardiac surgery found that clonidine did not
reduce the rate of death or non-fatal myocardial infarction.[106] Alpha-2 agonists are not, therefore,
recommended for non-cardiac surgery patients.[104]
Antibiotic cover:
• Antibiotic therapy is indicated for patients undergoing elective and emergent repair of ruptured
AAA to cover gram-positive and gram-negative organisms (i.e., Staphylococcus aureus ,
Staphylococcus epidermidis , and enteric gram-negative bacilli) and prevent graft infection.
• Broad-spectrum antibiotic coverage is tailored to patient clinical presentation and cultures, and in
accordance with local protocols.
Ruptured AAA
Patients with the triad of abdominal and/or back pain, pulsatile abdominal mass, and hypotension warrant
immediate resuscitation and surgical evaluation as repair offers the only potential cure.[47] [107] However,
most patients with rupture will not survive to reach theatre. Overall mortality is about 90%;[83]mortality in
those that reach the operating suite is 50%.[47]
[Fig-4]
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17
TREATMENT
EVAR is the most efficacious method for repair, aortoiliac anatomy permitting; otherwise, traditional
open repair is performed.[1] [108] [109] [110] [111] [112] [113]Operative mortality for open repair is
48%.[114]Despite frequent prolonged ICU and hospital lengths of stay, around 60% survive with long-term
survival similar to that of the general population. Data support cost effectiveness.[114] [115] [116]
Abdominal aortic aneurysm
Treatment
Supportive treatment of ruptured AAA
Standard resuscitation measures are initiated immediately. This includes:
•
•
•
•
•
•
Airway management (supplemental oxygen or endotracheal intubation)
Intravenous access (central venous catheter)
Arterial catheter
Notify anaesthetic, ICU, and operating teams
Urinary catheter
Hypotensive resuscitation: aggressive fluid replacement may cause dilutional and hypothermic
coagulopathy and secondary clot disruption from increased blood flow, increased perfusion
pressure, and decreased blood viscosity thereby exacerbating bleeding.[108] [112] [117] [118]
Infusing more than 3.5 litres of fluid preoperatively may increase the relative risk of death.[108] A
target systolic BP of 50 to 70 mmHg and withholding fluids is advocated preoperatively.[112] [117]
[118]
• Blood product (packed red cells, platelets, and fresh frozen plasma) availability and transfusion for
resuscitation, severe anaemia, and coagulopathy.
Symptomatic but not ruptured AAA
In patients with symptomatic aortic aneurysms, repair is indicated regardless of diameter.[73] The
development of new or worsening pain may herald aneurysm expansion and impending rupture. Repair is
undertaken within 24 hours; comorbid diseases are medically optimised.[1] [47]
Incidental finding of small AAA
For AAA detected as an incidental finding, repair is deferred until the theoretical risk of rupture exceeds
the estimated risk of operative mortality. Generally, repair is indicated in patients with large asymptomatic
AAA (e.g., with a diameter exceeding 5.5 cm in men or 5.0 cm in women in the US), although treatment
decisions based on greater size may differ in other countries (e.g., UK).[1] [74] [75] [76] [77] [78] Current
evidence and guidelines suggest that surveillance with selective repair is most appropriate for older male
patients with significant comorbidities. Young, healthy patients, and especially women, with AAA between
5.0 and 5.4 cm may benefit from early repair.[47] [74] [75] [76] [77] [119]
TREATMENT
• While long-term survival was equivalent in the United Kingdom Small Aneurysm Trial (UKSAT)
and the Aneurysm Detection and Management (ADAM) trial for both immediate surgery and
surveillance groups, a trend towards a beneficial effect of early surgery was observed in both
studies in the younger patient and for those with larger aneurysms[47] [75] [76] [77] [78]
• The observation that EVAR is associated with reduced perioperative mortality prompted the
Comparison of surveillance versus endografting for small aneurysm repair (CAESAR) and Positive
impact of endovascular options for treating aneurysm early (PIVOTAL) trials in an effort to compare
immediate EVAR with surveillance and selective EVAR, but neither trial has been designed to
determine whether immediate EVAR might be beneficial or harmful for specific AAA size ranges or
age subgroups.[47] [120]
Additionally, elective repair should be considered for patients that present with a saccular aneurysm.[47]
Medical goals for asymptomatic small aneurysms include:
1. Surveillance:
18
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Abdominal aortic aneurysm
Treatment
• Infra-/juxtarenal AAAs measuring 4.0 to 5.4 cm in diameter with ultrasonography (USS)/CT should
be monitored every 6 to 12 months.[73]
• AAAs <4.0 cm require USS every 2 to 3 years.[73]
• Expansion rates should be considered, as some advocate that expansion of 4 to 8 mm over 12
months suggests instability.[1]
2. Control modifiable risk factors for expansion and rupture:
• Smoking cessation - nicotine-replacement therapy, nortriptyline, and bupropion, or counselling.[1]
[7] [11] [26] [27] [121] [122] [123]
• Beta-blockers may be used to reduce the rate of aneurysm expansion,[47] [124] [125] [126]
although clinical trials have not supported this.
3. Aggressively manage other cardiovascular disease.
• Other modifiable cardiovascular risk factors (such as hyperlipidaemia) can be treated, and statins
may be considered to reduce the risk of AAA enlargement.[47]
Incidental finding of large AAA
Generally, repair is indicated in patients with large asymptomatic AAA (e.g., with a diameter exceeding 5.5
cm in men or 5.0 cm in women in the US), although treatment decisions based on greater size may differ
in other countries (e.g., UK). Repair of aneurysms ≥5.5 cm offers a survival advantage.[1] [75] [76] [77]
[78] Elective repair should be also considered for patients that present with a saccular aneurysm.[47]
Data suggest that in patients with large AAAs (ranging from 5 to 5.5 cm) undergoing elective repair, EVAR
is equivalent to open repair in terms of overall survival, although the rate of secondary interventions is
higher for EVAR.[87] [88] EVAR also reduces AAA-related mortality (but not longer-term overall survival)
in patients unsuitable for open repair.[89]
Elective repair in asymptomatic patients allows for preoperative assessment, cardiac risk stratification,
and medical optimisation of other comorbidities. CAD remains the leading cause of early and late
mortality after AAA repair. Preoperative beta-blockade may be reasonable in patients with intermediateor high-risk myocardial ischaemia, and those with 3 or more RCRI (revised cardiac risk index) risk factors
(e.g., diabetes mellitus, heart failure, CAD, renal insufficiency, stroke). When indicated, beta-blocker
therapy should be started more than 1 day before surgery.[104] [105]
American College of Cardiology/American Heart Association Practice Guidelines (compilation of 2005
and 2011 guideline recommendations) state: "open or endovascular repair of infrarenal AAAs is indicated
in patients who are good surgical candidates… open aneurysm repair is reasonable to perform in patients
who cannot comply with the periodic long-term surveillance required after endovascular repair."[73]
EVAR leak
Endoleak is persistent blood flow outside the graft and within the aneurysm sac.[127] [128]
Type I:
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19
TREATMENT
Risk of endoleak following EVAR is 24%.[127] Endoleak is not a complication following open repair. There
are 5 types of endoleak.
Abdominal aortic aneurysm
Treatment
• Leak at the attachment site (proximal/distal end of the endograft or iliac occluder); usually
immediate, but delayed leaks may occur.
[Fig-5]
• Repair is indicated upon discovery (endovascular extension grafts or conversion to open repair if
necessary).[47]
[Fig-6]
[Fig-7]
Type II:
• Patent branch leak.
[Fig-8]
• Spontaneous resolution may occur, although persistence may result in sac growth.[129]
• If a type II endoleak or other abnormality of concern is observed on contrast-enhanced CT imaging
at 1 month after EVAR, postoperative imaging at 6 months is recommended.[47]
• Treatment remains controversial and is advocated either if persistent at 6 to 12 months or when
aneurysm sac size increases.[130] [131] [132] [133]
• Treatment of choice is transarterial coil embolisation, although laparoscopic ligation of collateral
branches, direct percutaneous translumbar puncture of the sac, translumbar embolisation, and
transcatheter transcaval embolisation have been reported.[128] [130] [131] [132] [134] [135] [136]
[137]
Type III:
• Graft defect with leak through fabric tears, graft disconnection, or disintegration of the fabric.[127]
[128]
• Repair is indicated upon discovery (endovascular stent graft extension).[131] [47]
Type IV:
• Leak from graft wall porosity.[127] [128]
• These leaks are uncommon with newer stent grafts and are self-limited.[47] [131]
Type V:
TREATMENT
• Endotension is increased intrasac pressure after EVAR without visualised endoleak on delayed
contrast CT scans.
• There is no standardised method to measure endotension or consensus on indicated therapy in
the absence of aneurysm enlargement; however, treatment of endotension to prevent aneurysm
rupture is suggested in selected patients with continued aneurysm expansion. [47] [128] Bag-valvemask ventilation animated demonstration
Equipment needed
•
•
•
•
•
20
Personal protective equipment, including gloves
Bag-valve-mask apparatus
Oxygen
Reservoir bag attached to the bag-valve-mask apparatus
Suction
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Abdominal aortic aneurysm
Treatment
• Oropharyngeal airway (have available to use if needed)
• Nasopharyngeal airway (have available to use if needed)
• Resuscitation kit.
Contraindications
Complete upper airway obstruction is an absolute contraindication for bag-valve-mask ventilation.
If there is suspicion of a cervical spine injury, airway opening should ideally be achieved by jaw
thrust or chin lift rather than head tilt, while maintaining manual inline stabilisation (MILS). If the
airway remains obstructed despite these measures, perform a head tilt using small increments until
the airway is open, while maintaining MILS.[138]
When it is clear from the outset that the patient needs a definitive airway (e.g., in the unconscious
patient with a severe head and facial injury) call for help early while maintaining a patent airway by
simple means until skilled help arrives.
Consider the level of the airway obstruction. Laryngospasm due to anaphylaxis, an inhalation burn,
near drowning, or a foreign body will not improve significantly with simple airway manoeuvres, and
the patient may need intubation or advanced airway procedure.
Indications
• Respiratory failure
• Failed intubation.
Complications
•
•
•
•
Aspiration
Hypoventilation
Hyperventilation
Cervical spine injury.
Any significant leak will cause hypoventilation of the airway and can cause gas to be forced into the
stomach, heightening the risk of aspiration.
Aftercare
Continue to resuscitate the patient in keeping with life support guidelines, using ABCDE principles.
Send for assistance as soon as possible.
If resuscitation is successful and the patient regains control of their own airway, this should be
regularly reassessed. Measure arterial blood oxygen saturation as soon as practical by arterial
blood gas sampling and/or pulse oximetry and titrate inspired oxygen to maintain a blood arterial
oxygen saturation in the range of 94% to 98%.[138]
Central venous catheter insertion animated demonstration
Ultrasound-guided insertion of a non-tunnelled central venous catheter (CVC) into the right internal
jugular vein using the Seldinger insertion technique.
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21
TREATMENT
If the resuscitation continues or the patient’s Glasgow Coma Scale is less than 8, consider insertion
of an endotracheal tube.
Abdominal aortic aneurysm
Treatment
Equipment needed
• Ultrasound appliance, with sterile probe cover and sterile transducer gel
• CVC pack containing CVC and screw caps, guidewire, introducer, scalpel blade, cannulation
needle, and syringe
• Antiseptic preparation plus swabs for skin preparation or pre-packaged skin preparation
device
• Sterile gloves, sterile gown, and eye protection
• Local anaesthetic (e.g., 1% or 2% lignocaine) drawn up in syringe, with 23-gauge blue and
25-gauge orange needles
• Fenestrated sterile drape or occlusive transparent drape
• Extra 10 mL syringes with heparin sodium solution or 0.9% saline flush
• Suture and occlusive dressing
• Container for the disposal of sharps.
It is important to take into account the patient’s size when deciding how deeply to insert the central
venous catheter. Use of an inappropriately long length of catheter may increase the risk of serious
complications such as cardiac tamponade, cardiac perforation, and arrhythmias such as ventricular
tachycardia, due to irritation of the endocardium.[139] [140]
Contraindications
Absolute contraindications:
• Infection at insertion site[141]
• Anatomical obstruction (thrombosis, anatomic variance, stenosis)[141]
• Superior vena cava syndrome.[142]
Relative contraindications:
• Coagulopathy: it is generally accepted that the platelet count should be above 50 x 109/L
prior to insertion of a CVC and the international normalised ratio should be below 1.5[143]
• Systemic infection
• Presence of pacing wires or other indwelling catheters at insertion site[141]
• Right ventricular assist device
• Ipsilateral pneumothorax/haemothorax.[141]
Indications
TREATMENT
• Monitoring central venous pressure
• Poor peripheral venous access or when there is a need for repeated phlebotomy
• Prolonged intravenous chemotherapy and/or total parenteral nutrition, or repeated
administration of blood products[144]
• To deliver drugs unsuitable for peripheral infusion, such as venous sclerosants
• For multiple, continuous, or incompatible infusions.
Complications
• Technical or equipment failure: re-attempt with assistance, possibly at an alternative site
22
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Abdominal aortic aneurysm
Treatment
• Haemorrhage and haematoma formation: direct pressure is required to control bleeding,
particularly if accidental arterial puncture has occurred
• Arterial cannulation: remove needle/wire/catheter as soon as identified, and apply pressure
to control haemorrhage and reduce haematoma formation
• Catheter malpositioning: either cranially or extravenous. Remove catheter as soon as
identified. If the catheter is positioned in the right ventricle, withdraw 5 cm or more and repeat
chest radiograph
• Venous air embolism: minimise the risk of air being sucked into the vein by negative
intrathoracic pressures by using head-down tilt and careful technique
• Venous thrombosis: higher risk with subclavian or femoral lines
• Cardiac arrhythmias: withdrawing the guidewire or catheter should terminate arrhythmias
caused by ventricular irritation; patients should have cardiac monitoring throughout the
procedure[141]
• Cardiac tamponade: this may require pericardiocentesis or surgical intervention
• Carotid artery dissection: involve vascular surgeons immediately
• Loss of guidewire: will require retrieval by an interventional radiologist or vascular surgeons;
hold onto the guidewire with one hand at all times to avoid losing it in the patient’s vein
• CVC-related sepsis: serious and potentially preventable; observe strict sterile procedure and
local infection control policy
• Lung injury: haemothorax, pneumothorax, and chylothorax; this should not occur when
performing right internal jugular vein central line insertion, unless adopting a very low
approach in the neck.
Aftercare
After insertion of the CVC, it is essential to confirm correct positioning before using the line for its
intended purpose. This is important because ineffective positioning increases the risk of cardiac
tamponade and thrombosis.[141]The optimal position of the CVC tip is a subject of ongoing debate,
as no position is absolutely safe.[141] [145]
Positioning the tip in the high right atrium (intracardiac placement) carries the risk of cardiac
tamponade, and should be avoided,[145] although positions in the high and low superior vena cava
(SVC) are also not without risk: for example, risk of thrombosis.[145] For right internal jugular vein
CVC insertion it may be acceptable to aim for tip placement in the lower SVC, although this is by no
means universally accepted.[145] [146] Patients with additional risk factors for thrombosis, such as
those with cancer, may require different (e.g., lower) positioning of the CVC. In practice, this would
be a decision to make only with senior advice.[147]
Determine whether the CVC is correctly positioned using an erect chest radiograph. An erect chest
radiograph is mandatory following insertion of a CVC, both to confirm the position of the tip and to
check for evidence of complications such as pneumothorax and haemothorax.
Therefore, the tip should ideally lie at or above the level of the carina.[141] If the catheter is in too
far, the sutures/fixation can be removed and the catheter withdrawn back slightly before suturing/
fixing again. It is important to repeat the chest radiograph to reconfirm the position. However, if the
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23
TREATMENT
On the chest radiograph, the catheter should be seen to pass directly down the right side of
the neck, continuing inferiorly to the right side of the mediastinum such that the tip lies at the
approximate level of the carina. The carina is a radiological landmark, below which the tip is likely
to be below the pericardial reflection, and therefore within the pericardial sac.[147]
Abdominal aortic aneurysm
Treatment
catheter is too high (i.e., not deep enough) it is not advisable to advance the catheter further as you
risk introducing bacteria into the circulation. A new catheter would need to be inserted, if necessary.
Ensure the patient is regularly observed for signs of complications. In the days to come, signs of
CVC-related sepsis should prompt immediate action in keeping with local guidance, with respect to
removal of the line, culture, and antibiotic treatment.
If the CVC is to be used for measurement of central venous pressure, the catheter should be
correctly connected to a transducer and calibrated properly to ensure accurate readings.
Female urethral catheterisation animated demonstration
Equipment needed
• Latex or silicone Foley catheter (14 French gauge for general use; sizes from 12 French to
24 French may be needed depending on the situation)
• Sterile drape
• Sterile paper towel (preferably fenestrated)
• Sterile gloves
•
•
•
•
•
•
Plastic apron
Sterile pot
Kidney dish
10 mL syringe filled with 10 mL sterile water (NOT saline)
Lubricating anaesthetic gel (e.g., lignocaine gel) in a pre-filled 10 mL syringe
Swabs and saline solution (not chlorhexidine or other cleaning solutions, as these can be
irritating to the skin).
Contraindications
Do not perform urethral catheterisation after pelvic trauma, especially if there is a suspicion of
urethral injury that may accompany a pelvic fracture, for example. In patients with a urethral
injury, there is a risk that the catheter may pass straight through the urethra and into the
surrounding tissues. In these patients, arrange for further imaging of the urethra before attempting
catheterisation.
If you fail to insert a urethral catheter on two or more occasions, seek a more experienced clinician
for assistance. It may be necessary to use a curved coude tip catheter, a smaller or larger catheter,
or a three-way irrigation catheter.
If the patient has capacity and refuses urethral catheterisation after sufficient communication and
understanding, do not perform the procedure against their wishes.
Indications
TREATMENT
• Acute retention of urine
• Perioperative urinary collection (e.g., patients undergoing abdominal surgery always need
catheterisation as it is important that the bladder is fully emptied; if the bladder were full,
there is a risk of it accidentally being cut during the operation)
• Accurate measurement of urine output in patients who are acutely or critically unwell
• Re-insertion of long-term urinary catheter
• Chronic bladder obstruction and neuropathic bladder
24
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Abdominal aortic aneurysm
Treatment
• Bladder irrigation or instillation.
Patients with urinary incontinence and immobility may need catheterisation but these are not clear
indications. The risk of infection must be balanced against the convenience of the catheter.
Complications
• Failure to catheterise:seek help from a more experienced clinician
• Urinary tract infection: remove the catheter and give antibiotics as directed by local policy
• Bleeding: minor bleeding is common and generally stops spontaneously; for more significant
urethral haemorrhage seek expert advice from a more experienced clinician
• Blocked catheter: may result from clots or other debris. Aspirating or flushing the catheter
with sterile water may clear the lumen; however, repositioning may be required. If haematuria
and retention of clots occurs, irrigate with a three-way catheter and contact the urology team.
Aftercare
Unlike catheterisation of male patients, incorrect positioning of the catheter is common in women
as the urethral meatus is so close to the vaginal opening. It is very important to ensure that urine
is flowing before inflating the balloon. Flowing urine is confirmation that the tip of the catheter lies
within the bladder. If no urine drains do not inflate the balloon, as the tip, and therefore the balloon,
may still be in the urethra. Inflating the balloon at this point could lead to urethral injury.
Documentation:
Clearly document that the patient’s consent was obtained. Also document the volume of sterile
water instilled into the balloon and the residual volume of urine, as well as any complications that
occurred during the procedure. It may also be sensible to document the colour and quality of the
urine produced.
Catheter bag:
After successful positioning of the catheter ensure it is draining adequately and that the correct type
of urine collection bag is attached.
• An urometer may be required to measure accurate hourly urine volumes
• Various leg-bag attachments are available for the ambulant patient.
Removal:
Once the patient no longer requires the catheter, remove it as soon as possible to prevent infection.
Deflate the balloon before removing the catheter.
Male urethral catheterisation animated demonstration
Equipment needed
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25
TREATMENT
• Latex or silicone Foley catheter (14 French gauge for general use; with prostatic hypertrophy
a larger 16 French gauge may be easier to pass due to its greater rigidity; sizes from 12
French to 24 French may be needed depending on the situation)
• Sterile drape
• Sterile paper towel (preferably fenestrated)
• Sterile gloves
Abdominal aortic aneurysm
•
•
•
•
•
•
Treatment
Plastic apron
Sterile pot
Kidney dish
10 mL syringe filled with 10 mL sterile water (NOT saline)
Lubricating anaesthetic gel (e.g., lignocaine gel) in a pre-filled 10 mL syringe
Swabs and saline solution (not chlorhexidine or other cleaning solutions, as these can be
irritating to the skin).
Contraindications
Do not perform urethral catheterisation after pelvic trauma, especially if there is suspicion of
urethral injury that may accompany a pelvic fracture, for example. In patients with a urethral
injury, there is a risk that the catheter may pass straight through the urethra and into the
surrounding tissues. In these patients, arrange for further imaging of the urethra before attempting
catheterisation.
If you fail to insert a urethral catheter on two or more occasions, seek a more experienced clinician
for assistance. It may be necessary to use a curved coude tip catheter, a smaller or larger catheter,
or a three-way irrigation catheter.
If the patient has capacity and refuses urethral catheterisation after sufficient communication and
understanding, do not perform the procedure against their wishes.
Phimosis, hypospadias, and penile deformity may make urethral catheterisation more difficult but
they are not contraindications.
Indications
•
•
•
•
•
•
Acute retention of urine
Perioperative urinary collection
Accurate measurement of urine output in the acutely or critically unwell
Re-insertion of a long-term urinary catheter
Prostatic enlargement with chronic bladder obstruction
Bladder irrigation or instillation.
Patients with urinary incontinence and immobility may need catheterisation but these are not clear
indications. Clinicians must balance the risk of infection against the convenience of the catheter.
Complications
TREATMENT
• Failure to catheterise: seek help from a more experienced clinician
• Urinary tract infection: remove the catheter and give antibiotics as directed by local policy
• Bleeding: minor bleeding is common and generally stops spontaneously; for more significant
urethral haemorrhage seek expert advice from a more experienced clinician
• Creating a false passage: forceful catheterisation can lead to formation of blind ending
passages making it increasingly difficult to catheterise the true urethra and creating traumatic
bleeding; avoid using force during catheterisation at all times
• Blocked catheter: may result from clots or other debris. Aspirating or flushing the catheter
with sterile water may clear the lumen; however, repositioning may be required. The patient
may need irrigation with a three-way catheter if haematuria and retention of clots recur.
26
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Treatment
Abdominal aortic aneurysm
Aftercare
Documentation:
Clearly document that the patient’s consent was obtained. Also document the volume of sterile
water instilled into the balloon and the residual volume of urine. It may also be sensible to
document the colour and quality of the urine produced, and whether there were any complications
to the procedure.
Catheter bag:
After successful positioning of the catheter ensure it is draining adequately and that the correct type
of urine collection bag is attached.
• A urometer may be required to measure hourly urine volumes accurately
• Leg-bag attachments are available for the ambulant patient.
Removal:
Once the patient no longer requires the catheter, remove it as soon as possible to prevent infection.
Deflate the balloon before removing the catheter.
Treatment details overview
Consult your local pharmaceutical database for comprehensive drug information including contraindications,
drug interactions, and alternative dosing. ( see Disclaimer )
Acute
( summary )
Patient group
ruptured AAA
symptomatic, but not ruptured AAA
Tx line
1st
Treatment
standard resuscitation measures
plus
urgent surgical repair
plus
perioperative antibiotic therapy
1st
semi-urgent surgical repair
plus
preoperative cardiovascular risk reduction
plus
perioperative antibiotic therapy
Ongoing
incidental finding: asymptomatic
small AAA
Tx line
1st
Treatment
TREATMENT
Patient group
( summary )
surveillance
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27
Treatment
Abdominal aortic aneurysm
Ongoing
( summary )
plus
incidental finding: large AAA
elective surgical repair
plus
preoperative cardiovascular risk reduction
plus
perioperative antibiotic therapy
1st
corrective procedure
plus
preoperative cardiovascular risk reduction
plus
perioperative antibiotic therapy
TREATMENT
endovascular repair leak requiring
treatment
1st
aggressive cardiovascular risk
management
28
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Treatment
Abdominal aortic aneurysm
Treatment options
Acute
Patient group
ruptured AAA
Tx line
1st
Treatment
standard resuscitation measures
» The airway is managed with supplemental
oxygen and endotracheal intubation.
» A central venous catheter is inserted.
» Monitoring requires insertion of an arterial
catheter and urinary catheter.
» A target systolic BP of 50 to 70 mmHg
and withholding fluids is advocated
preoperatively.[112] [117] [118]
» Aggressive fluid replacement may cause
dilutional and hypothermic coagulopathy and
secondary clot disruption from increased
blood flow, increased perfusion pressure, and
decreased blood viscosity thereby exacerbating
bleeding.[108] [112] [117] [118] Infusing more
than 3.5 L of fluid preoperatively may increase
the relative risk of death.[108]
plus
urgent surgical repair
» Endovascular AAA repair (EVAR) is the most
efficacious test for repair, aortoiliac anatomy
permitting; otherwise, traditional open repair is
performed.[1] [108] [112] [109] [110] [111] [113]
» Operative mortality for open repair is
48%.[114] Despite frequent prolonged ICU and
hospital lengths of stay, around 60% survive with
long-term survival similar to that of the general
population. Data support cost effectiveness.[114]
[115] [116]
plus
perioperative antibiotic therapy
» Antibiotic therapy is indicated for patients
undergoing emergency repair of ruptured AAA
to cover gram-positive and gram-negative
organisms and prevent graft infection.
symptomatic, but not ruptured AAA
1st
semi-urgent surgical repair
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29
TREATMENT
» Broad-spectrum antibiotic coverage is tailored
to patient clinical presentation and cultures, and
in accordance with local protocols.
Treatment
Abdominal aortic aneurysm
Acute
Patient group
Tx line
Treatment
» Aorto-iliac anatomy permitting, endovascular
AAA repair (EVAR) may be offered to these
patients.
» Urgent open repair of symptomatic unruptured
AAAs carries increased morbidity and mortality
with a rate between that of ruptured AAA repair
and elective repair.[1] [148] EVAR in this setting
demonstrates promising results with lower firstmonth mortality.[1] [113]
» Comorbid diseases are medically optimised.[1]
[47]
plus
preoperative cardiovascular risk reduction
» Preoperative beta-blockade may be
reasonable in patients with intermediate- or
high-risk myocardial ischaemia, and those
with 3 or more RCRI (revised cardiac risk
index) risk factors (e.g., diabetes mellitus, heart
failure, CAD, renal insufficiency, stroke). When
indicated, beta-blocker therapy should be started
more than 1 day before surgery.[104] [105]
» A short-acting beta-blocker such as metoprolol
allows for dosing adjustment within a few days.
Atenelol and propanolol have also been used. [1]
[149]
» Doses should preferably be started 2 to 7 days
before surgery.[104]
» Perioperative statin use reduces
cardiovascular events.[104]
» A large, multi-centre study of patients
undergoing non-cardiac surgery found that
clonidine did not reduce the rate of death or nonfatal myocardial infarction.[106] Alpha-2 agonists
are not, therefore, recommended for non-cardiac
surgery patients.[104] [104]
plus
perioperative antibiotic therapy
TREATMENT
» Perioperative antibiotic therapy is given. Broadspectrum antibiotic coverage is necessary, in
accordance with local protocols.
Ongoing
Patient group
30
Tx line
Treatment
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Treatment
Abdominal aortic aneurysm
Ongoing
Patient group
incidental finding: asymptomatic
small AAA
Tx line
1st
Treatment
surveillance
» For AAA detected as an incidental finding,
repair is deferred until the theoretical risk of
rupture exceeds the estimated risk of operative
mortality. Generally, repair is indicated in
patients with large asymptomatic AAA (e.g.,
with a diameter exceeding 5.5 cm in men or 5.0
cm in women in the US), although treatment
decisions based on greater size may differ in
other countries (e.g., UK).[1] [74] [75] [76] [77]
[78]
» Surveillance with selective repair is most
appropriate for older male patients with
significant comorbidities. Young, healthy
patients, and especially women, with AAA
between 5.0 and 5.4 cm may benefit from early
repair.[47] [74] [75] [76] [77]
» Monitor infra-/juxtarenal AAAs measuring
4.0 to 5.4 cm in diameter with ultrasonography
(USS)/CT every 6 to 12 months.[73]
» AAAs <4.0 cm require USS every 2 to 3
years.[73]
plus
aggressive cardiovascular risk
management
» Patients should be encouraged to stop
smoking and offered drug therapy to assist with
this if needed.
» Beta-blockers may be used to reduce the
rate of aneurysm expansion, [47] [124] [125]
[126] although clinical trials have not supported
this.
» Other modifiable cardiovascular risk factors
(such as hyperlipidaemia) can be treated, and
statins may be considered to reduce the risk of
AAA enlargement.[47]
incidental finding: large AAA
1st
elective surgical repair
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31
TREATMENT
» Generally, repair is indicated in patients with
large asymptomatic AAA (e.g., with a diameter
exceeding 5.5 cm in men or 5.0 cm in women
in the US), although treatment decisions based
on greater size may differ in other countries
(e.g., UK). Repair of aneurysms ≥5.5 cm offers a
survival advantage.[1] [75] [76] [77] [78]
Treatment
Abdominal aortic aneurysm
Ongoing
Patient group
Tx line
Treatment
» Young, healthy patients, and especially
women, with AAA between 5.0 and 5.4 cm may
benefit from early repair.[47] [74] [75] [76] [77]
» Data suggest that in patients with large
AAAs (ranging from 5 to 5.5 cm) undergoing
elective repair, endovascular aneurysm repair
(EVAR) is equivalent to open repair in terms of
overall survival, although the rate of secondary
interventions is higher for EVAR.[87] [88]
EVAR also reduces AAA-related mortality (but
not longer-term overall survival) in patients
unsuitable for open repair.[89]
» Patients with greater risk of perioperative
morbidity and mortality (i.e., COPD, multiple
previous abdominal operations) may benefit from
a less invasive approach, aorto-iliac anatomy
permitting. Younger, healthier patients may
benefit from the durability of an open repair.
Reasons for deferring care may include terminal
illness (i.e., cancer) such that life expectancy is
<6 to 12 months and patient choice.
plus
preoperative cardiovascular risk reduction
» Preoperative beta-blockade may be
reasonable in patients with intermediate- or
high-risk myocardial ischaemia, and those
with 3 or more RCRI (revised cardiac risk
index) risk factors (e.g., diabetes mellitus, heart
failure, CAD, renal insufficiency, stroke). When
indicated, beta-blocker therapy should be started
more than 1 day before surgery.[104] [105]
» A short-acting beta-blocker such as metoprolol
allows for dosing adjustment within a few days.
Atenelol and propanolol have also been used. [1]
[149]
» Doses should preferably be started 2 to 7 days
before surgery.[104]
» Perioperative statin use reduces
cardiovascular events.[104]
TREATMENT
» A large, multi-centre study of patients
undergoing non-cardiac surgery found that
clonidine did not reduce the rate of death or nonfatal myocardial infarction.[106] Alpha-2 agonists
are not, therefore, recommended for non-cardiac
surgery patients.[104] [104]
plus
32
perioperative antibiotic therapy
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Treatment
Abdominal aortic aneurysm
Ongoing
Patient group
Tx line
Treatment
» Perioperative antibiotic therapy is given. Broadspectrum antibiotic coverage is necessary, in
accordance with local protocols.
endovascular repair leak requiring
treatment
1st
corrective procedure
» Endoleak is persistent blood flow outside the
graft and within the aneurysm sac.[127] [128]
» Risk of endoleak following endovascular
aneurysm repair (EVAR) is 24%.[127] Endoleak
is not a complication following open repair. There
are 5 types of endoleak and management is
dependant upon type.
» Type I: repair is indicated upon discovery
(endovascular extension grafts or conversion to
open repair if necessary).[47]
[Fig-6]
[Fig-7]
» Type II: treatment remains controversial and is
advocated either if persistent at 6 to 12 months
or when aneurysm sac size increases.[130] [131]
[132] [133] Treatment of choice is transarterial
coil embolisation, although laparoscopic ligation
of collateral branches, direct percutaneous
translumbar puncture of the sac, translumbar
embolisation, and transcatheter transcaval
embolisation have been reported.[128] [130]
[131] [132] [134] [135] [136] [137]
» Type III: repair is indicated upon discovery
(endovascular stent graft extension).[47] [131]
» Type IV: these leaks are uncommon with
newer stent grafts and are self-limited, requiring
no treatment.[47] [131]
» Type V: there is no standardised method
to measure endotension or consensus on
indicated therapy in the absence of aneurysm
enlargement; however, treatment of endotension
to prevent aneurysm rupture is suggested in
selected patients with continued aneurysm
expansion.[47] [128]
preoperative cardiovascular risk reduction
» Preoperative beta-blockade may be
reasonable in patients with intermediate- or
high-risk myocardial ischaemia, and those
with 3 or more RCRI (revised cardiac risk
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33
TREATMENT
plus
Treatment
Abdominal aortic aneurysm
Ongoing
Patient group
Tx line
Treatment
index) risk factors (e.g., diabetes mellitus, heart
failure, CAD, renal insufficiency, stroke). When
indicated, beta-blocker therapy should be started
more than 1 day before surgery.[104] [105]
» A short-acting beta-blocker such as metoprolol
allows for dosing adjustment within a few days.
Atenelol and propanolol have also been used. [1]
[149]
» Doses should preferably be started 2 to 7 days
before surgery.[104]
» Perioperative statin use reduces
cardiovascular events.[104]
» A large, multi-centre study of patients
undergoing non-cardiac surgery found that
clonidine did not reduce the rate of death or nonfatal myocardial infarction.[106] Alpha-2 agonists
are not, therefore, recommended for non-cardiac
surgery patients.[104]
plus
perioperative antibiotic therapy
TREATMENT
» Perioperative antibiotic therapy is given. Broadspectrum antibiotic coverage is necessary, in
accordance with local protocols.
34
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Abdominal aortic aneurysm
Treatment
Emerging
Dox ycycline or roxithromycin
Doxycycline is a non-specific inhibitor of matrix metalloproteinases (MMP) that promote degradation of
collagen and elastin and are integral to aneurysm formation.[1] [14]Targeted gene disruption of MMP-9 in
mice suppresses the development of experimental AAA and both MMP-2 and -9 are necessary to induce
experimental AAA formation in mice.[150] [151] [152]Animal models have shown that continuous periaortic
infusion of doxycycline lowers the effective dose, and can effectively suppress experimental AAAs serving
as a prototype for adjuvant treatment modalities that complement endovascular AAA exclusion and may
inhibit progressive expansion of aortic aneurysms.[1] [153] [154] One clinical trial has found that prolonged
administration of doxycycline for 6 months is safe and well tolerated by patients with small asymptomatic
AAAs and is associated with a gradual reduction in plasma MMP-9 levels.[1] [155]Another small randomised
trial assessing the ability of doxycycline to inhibit the growth of aortic aneurysms noted no growth in
doxycycline-treated patients at 6 and 12 months.[156] [157]Further studies are needed to evaluate the
long-term effects of doxycycline on the rate and extent of aneurysm growth and the potential use of plasma
MMP-9 levels as a biomarker of aneurysm disease progression, but there appear to be sufficient preliminary
data to support a large prospective randomised trial of doxycycline to prevent aneurysm expansion.[156]At
this time, however, insufficient data exist to recommend use of doxycycline or roxithromycin.[47] [158]
TREATMENT
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35
Follow up
Abdominal aortic aneurysm
FOLLOW UP
Recommendations
Monitoring
In patients with small aneurysms, monitor infra-/juxtarenal AAAs measuring 4.0 to 5.4 cm in diameter
with ultrasonography (USS)/CT every 6 to 12 months.[73]AAAs <4.0 cm require USS every 2 to 3
years.[73]Consider expansion rates, as some advocate expansion of 4 to 8 mm over 12 months suggests
instability.[1]
As late aneurysm formation may be noted in approximately 1%, 5%, and 20% of patients at 5, 10,
and 15 years after open repair, respectively, follow-up non-contrast CT imaging at 5-year intervals is
recommended.[47]
Previous recommendations regarding post-endovascular repair (post-EVAR) surveillance included
CT imaging at 1, 6, and 12 months postoperatively and yearly thereafter to evaluate for late graft
complications (i.e., migration, occlusion, and endoleak).[44] However, more recent concerns regarding the
frequent use of CT scanning, cost, and cumulative radiation exposure/potential lifetime cancer risk have
resulted in a shift towards colour duplex ultrasound imaging for surveillance. Current recommendations
include contrast-enhanced CT imaging at 1 and 12 months during the first year following EVAR. If
neither endoleak nor AAA enlargement is documented during first year after EVAR, colour duplex
ultrasonography is suggested as an alternative to CT imaging for annual postoperative surveillance with
non-contrast CT imaging every 5 years.[47] [163] [153] Antibiotic prophylaxis of graft infection is required
prior to bronchoscopy, gastrointestinal or genitourinary endoscopy, and any dental procedure that may
lead to bleeding.[47]
Generalised sepsis, groin drainage, pseudoaneurysm formation, or ill-defined pain after open repair
or EVAR should prompt evaluation of graft infection.[47]GI bleeding after open repair or EVAR should
prompt evaluation of an aortoenteric fistula.[47]
Patient instructions
Patients should be educated on the importance of smoking cessation (including counselling and
pharmacotherapy as needed), and of blood pressure and cholesterol control.
Complications
Complications
ureteral obstruction
Timeframe
long term
Likelihood
low
Ureteric obstruction is related to encasement of the ureters in an inflammatory perianeurysmal fibrosis
of unresolved aetiology rather than secondary to aneurysm compression.[160] Most often, ureteral
compression is associated with inflammatory aortic aneurysm. Extensive retroperitoneal adhesions may
result in ureteral obstruction in 18% of patients. The inferior vena cava may become involved as well.[161]
functional gastric outlet obstruction
long term
low
Duodenal obstruction is a consequence of compression of the duodenum in its fixed retroperitoneal course
between the aneurysmal aorta and the superior mesenteric artery.[160]
distal embolisation
variable
low
Incidence is 3% to 29%, most commonly affecting the digits (blue toe syndrome). There is a 5% incidence
of distal embolisation resulting in limb-threatening ischaemia, digital ischaemia, and calf myonecrosis.[162]
36
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Abdominal aortic aneurysm
Follow up
Prognosis
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37
FOLLOW UP
The natural course involves slow and steady growth with ultimate progression to rupture. Most patients
with rupture will not survive to reach the operating theatre; overall mortality is around 90%.[83] Given the
morbidity and mortality associated with surgical intervention, repair is typically deferred until the theoretical
risk of rupture exceeds the estimated risk of operative mortality. The majority of patients undergoing open
repair remain without significant graft-related complications during the remainder of their lives (0.4% to 2.3%
incidence of late graft-related complications).[1] [159] Five-year survival rates after intact aneurysm repair
average 60% to 75%. Those undergoing endovascular repair (EVAR) are more likely to have a delayed
complication and require re-intervention.
Guidelines
Abdominal aortic aneurysm
Diagnostic guidelines
Europe
Abdominal aortic aneurysm screening: how it works
Published by: Public Health England
Last published: 2015
Summary: Provides information about the NHS AAA screening programme, and the tests and processes
involved.
North America
GUIDELINES
ACC/AHA guideline on perioperative cardiovascular evaluation and
management of patients undergoing noncardiac surgery
Published by: American College of Cardiology; American Heart
Association
Last published: 2014
Summary: Clinical practice guideline including recommendations about preoperative risk assessment
and cardiac testing in the adult patient undergoing non-cardiac surgery.
The care of patients with an abdominal aortic aneurysm: the Society for
Vascular Surgery practice guidelines
Published by: Society for Vascular Surgery
Last published: 2009
Summary: Provides recommendations for patient evaluation and risk of rupture in AAA, and for selecting
surgical or endovascular intervention, peri- and intra-operative strategies, follow-up, and treatment of
complications.
Treatment guidelines
Europe
Endovascular stent-grafts for the treatment of abdominal aortic aneurysms
Published by: National Institute for Health and Care Excellence
Last published: 2009
Summary: Provides an appraisal of the use of grafts in the treatment of AAA.
Laparoscopic repair of abdominal aortic aneurysm
Published by: National Institute for Health and Care Excellence
Last published: 2007
Summary: These guidelines make recommendations on the laparoscopic repair of AAA.
Recommendations are made on who should carry out the procedure, and the information given to patients
and their Trust.
38
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Abdominal aortic aneurysm
Guidelines
Europe
Stent-graft placement in abdominal aortic aneurysm
Published by: National Institute for Health and Care Excellence
Last published: 2006
Summary: These guidelines make recommendations on the information clinicians should ensure patients
understand about the procedure and the potential risks involved. The guidelines also advise on patient
selection for the procedure.
North America
ACC/AHA guideline on perioperative cardiovascular evaluation and
management of patients undergoing noncardiac surgery
Published by: American College of Cardiology; American Heart
Association
Last published: 2014
GUIDELINES
Summary: Guideline addressing pharmacotherapeutic and anaesthetic considerations for non-cardiac
surgery patients.
Management of patients with peripheral artery disease (compilation of 2005
and 2011 ACCF/AHA guideline recommendations)
Published by: American College of Cardiology Foundation; American
Heart Association
Last published: 2013
Summary: Includes recommendations for the screening and management of patients with aneurysms of
the abdominal aorta.
The care of patients with an abdominal aortic aneurysm: the Society for
Vascular Surgery practice guidelines
Published by: Society for Vascular Surgery
Last published: 2009
Summary: Provides recommendations for patient evaluation and risk of rupture in AAA, and for selecting
surgical or endovascular intervention, peri- and intra-operative strategies, follow-up, and treatment of
complications.
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39
Abdominal aortic aneurysm
References
REFERENCES
Key articles
•
Chaikof EL, Brewster DC, Dalman RL, et al; Society for Vascular Surgery. The care of patients with
an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg.
2009;50(suppl 4):S2-S49. Full text Abstract
•
US Preventive Services Task Force. Final recommendation statement. Abdominal aortic aneurysm:
screening. June 2014. http://www.uspreventiveservicestaskforce.org/ (last accessed 6 June 2017).
Full text
•
Ferket BS, Grootenboer N, Colkesen EB, et al. Systematic review of guidelines on abdominal aortic
aneurysm screening. J Vasc Surg. 2012;55:1296-1304.
•
Anderson JL, Halperin JL, Albert NM, et al. 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.
Circulation. 2013;127:1425-1443. Full text Abstract
•
De Bruin JL, Baas AF, Buth J, et al; DREAM Study Group. Long-term outcome of open or
endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881-1889. Abstract
•
United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular versus open
repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1863-1871. Abstract
•
United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular repair of
aortic aneurysm in patients physically ineligible for open repair. N Engl J Med. 2010;362:1872-1880.
Abstract
•
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative
cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2014;130:e278-333. Full text Abstract
References
1.
Dehlin JM, Upchurch GR. Management of abdominal aortic aneurysms. Curr Treat Options Cardiovasc
Med. 2005;7:119-130. Abstract
2.
Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial
aneurysms. J Vasc Surg. 1991;13:452-458. Abstract
3.
McConathy WJ, Alaupovic P, Woolcock N, et al. Lipids and apolipoprotein profiles in men with
aneurysmal and stenosing aorto-iliac atherosclerosis. Eur J Vasc Surg. 1989;3:511-514. Abstract
4.
Saratzis A, Bown MJ. The genetic basis for aortic aneurysmal disease. Heart. 2014;100:916-922.
Abstract
40
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
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Abdominal aortic aneurysm
References
Tang T, Boyle JR, Dixon AK, et al. Inflammatory abdominal aortic aneurysms. Eur J Vasc Endovasc.
Surg. 2005;29:353-362. Abstract
6.
Gomes MN, Choyke PL, Wallace RB. Infected aortic aneurysms: a changing entity. Ann Surg.
1992;215:435-442. Full text Abstract
7.
Zankl AR, Schumacher H, Krumsdorf U, et al. Pathology, natural history and treatment of abdominal
aortic aneurysms. Clin Res Cardiol. 2007;96:140-151. Abstract
8.
Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;
(2):CD002945. Full text Abstract
9.
Minino AM, Heron MP, Murphy SL, et al. Deaths: final data for 2004. Natl Vital Stat Rep.
2007;55:1-119. Full text
10.
Solberg S, Singh K, Wilsgaard T, et al. Increased growth rate of abdominal aortic aneurysms in
women. The Tromso Study. Eur J Vasc Endovasc Surg. 2005;29:145-149. Abstract
11.
Singh K, Bonaa H, Jacobsen BK, et al. Prevalence of and risk factors for abdominal aortic aneurysms
in a population-based study: The Tromsø Study. Am J Epidemiol. 2001;154:236-244. Full text
Abstract
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BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
51
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Abdominal aortic aneurysm
Images
Images
Figure 1: Ultrasound of a 3.8 cm x 4.2 cm AAA
IMAGES
University of Michigan, specifically the cases of Dr Upchurch reflecting the Departments of Vascular Surgery
and Radiology
Figure 2: Various endovascular stent grafts used for endovascular repair (EVAR)
University of Michigan, specifically the cases of Dr Upchurch reflecting the Departments of Vascular Surgery
and Radiology
52
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Abdominal aortic aneurysm
Images
IMAGES
Figure 3: Endovascular repair (EVAR)
University of Michigan, specifically the cases of Dr Upchurch reflecting the Departments of Vascular Surgery
and Radiology
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
53
Images
IMAGES
Abdominal aortic aneurysm
Figure 4: CT scan of a ruptured AAA
University of Michigan, specifically the cases of Dr Upchurch reflecting the Departments of Vascular Surgery
and Radiology
54
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Abdominal aortic aneurysm
Images
IMAGES
Figure 5: Type I endoleak at the distal left iliac anastomosis (leak encircled)
University of Michigan, specifically the cases of Dr Upchurch reflecting the Departments of Vascular Surgery
and Radiology
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
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55
Images
IMAGES
Abdominal aortic aneurysm
Figure 6: Extension stent graft deployed for the same type I endoleak (encircled)
University of Michigan, specifically the cases of Dr Upchurch reflecting the Departments of Vascular Surgery
and Radiology
56
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Abdominal aortic aneurysm
Images
IMAGES
Figure 7: Resolution of the type I endoleak resolved after extension deployed
University of Michigan, specifically the cases of Dr Upchurch reflecting the Departments of Vascular Surgery
and Radiology
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
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57
Images
IMAGES
Abdominal aortic aneurysm
Figure 8: Type II endoleak (encircled) discovered on follow-up CT
University of Michigan, specifically the cases of Dr Upchurch reflecting the Departments of Vascular Surgery
and Radiology
58
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Abdominal aortic aneurysm
Disclaimer
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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
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59
Contributors:
// Authors:
Maureen K. Sheehan, MD
Assistant Professor
Department of Surgery, University of Texas Health Science Center, San Antonio, TX
DISCLOSURES: MKS declares that she has no competing interests.
// Acknowledgements:
Dr Maureen K. Sheehan would like to gratefully acknowledge Dr Dawn M. Barnes and Dr Gilbert R.
Upchurch, the previous contributors to this monograph.
DISCLOSURES: DMB and GRU declare that they have no competing interests.
// Peer Reviewers:
Ross Naylor, MBBS
Professor of Vascular Surgery
Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, UK
DISCLOSURES: RN declares that he has no competing interests.
William Pearce, MD
Chief of Division of Vascular Surgery
Department of Surgery, Northwestern Memorial Hospital, Chicago, IL
DISCLOSURES: WP declares that he has no competing interests.