How do we manage AAAs
once it's been diagnosed?
Let’s start with medical management.
For patients who are asymptomatic,
pharmacologic and lifestyle changes.
You know this to be a very common
theme in peripheral vascular disease.
Pharmacologic patients can be
placed on anti-lipid therapy.
Statins again for plaque
stability and antihypertensives.
Remember, we talked about
the wall stresses on the aorta.
Beta blockers are particularly
good at reducing wall stress.
And like all other vascular diseases,
lifestyle management is very important.
Number one, stop smoking.
And number two, weight loss.
This also reduces the likelihood of
hypercholesterolemia and hyperlipidemia.
What are some indications for surgery?
Remember, all symptomatic
patients with AAAs require surgery.
Now, let's discuss the asymptomatic patient.
if the diameter of the abdominal
aortic aneurysm is greater than 5.5 cm
or it's actually growing
faster than 0.5 cm per year,
these are potential indications for surgery.
The discussion has been for many years
now open versus endovascular techniques.
You may be familiar with the
concept of endovascular techniques.
This is a hybrid open
access to the femoral vessels,
eventually using interventional
radiology techniques to deploy a graft.
This is opposed to the tried-and-true
open method of opening the abdomen,
accessing the aorta,
removing the plaques and fixing the aneurysm.
Other benefits and downsides to each?
Of course, there are.
Endovascular techniques is minimally invasive.
These are done quickly and the patients
are usually out of the hospital within a day or two.
However, particularly in younger patients,
require lifelong surveillance,
but it is associated with
less perioperative morbidity.
In open traditional technique,
we know it to be durable.
It's been tested over many decades
and it may be more appropriate for young patients.
However, as previously described,
it has a little bit more perioperative morbidity.
Once it's decided that the
patient has indications for surgery,
let’s discuss the surgical options.
We discussed how there's
open and endovascular techniques.
Here, on this image,
is an exposed open
abdominal aortic aneurysm repair.
You’ll notice that in the middle of the graph
is already a graft placement
of the previous aneurysmic sac.
Next, let's take a look at endovascular deployment.
To the left of the screen,
you see the initial insertion of the graft.
This is done through the common femoral,
up the iliac,
through the common iliac, into the –
and past the aortic sac.
And to the right of the screen,
you see the aortic graft after deployment.
Remember, both open and endovascular techniques,
main goal is to bypass this aneurysmic sac.
This also restores laminar flow.
I’d like to pose a question to you.
When is screening necessary?
I’ll give you a second to think about it.
Here's some guidelines for
screening from preventative societies.
First, any man aged 65 to 75,
who have a history of smoking
greater than 100 cigarettes per year,
with no family history of AAAs,
should be offered an
ultrasound of the abdominal aorta.
Younger men between
the ages of 55 and 75
who have a family history of
AAA can also be offered one.
Don't forget, women also get AAAs even
though there is a male preponderance.
Women between the ages of 55 to 75
who have both a smoking history
of greater than 100 cigarettes per year
and a family history of AAA can be
offered an ultrasound of the abdomen.
Women of any age,
who have neither smoking history
nor family history of AAA,
should not be offered screening as their
incidence of an abdominal aortic aneurysm is low.
Now, let's move on to important
clinical pearls and high-yield information.
Remember, any patient who
presents with abdominal pain
that has a known aortic aneurysm
should prompt immediate
workup for possible rupture.
And if the classic clinical
scenario is presented to you
where the patient comes in with searing
abdominal pain radiating to the back,
you should immediately prompt
both workup and management
of an impending rupture.
Now, pay particular attention
to this high-yield information.
I’d like to pose a clinical scenario to you.
What if two days after a AAA repair,
either open or endovascularly,
you are called to the bedside because the
patient now is presenting with bloody stools.
What’s going on in your mind
and what are the differential diagnosis.
How will you manage this?
I’ll give you a second to think about this.
In this clinical scenario,
it’s the classic description of
ischemic colitis following a AAA repair.
The reason behind this is
the graft, whether it’s placed
endovascularly or open,
likely covered up the
inferior mesenteric artery.
the inferior mesenteric artery is
no longer supplying the sigmoid colon.
This can lead to ischemic colitis.
The workup includes
a flexible sigmoidoscopy
to identify areas of ischemia.
the inferior mesenteric artery
actually needs to be replanted.
Thank you for joining me
on this discussion of AAAs.