64 years old male patient has been referred to your vascular clinic from the spine clinic. He had MRI spine for chronic back pain which showed that he has 4.8 cm infra renal AAA. Please answer the following questions.
1- Please indicate How would you approach his history?
2- How would you perform clinical examination?
3- what investigation would you request?
4- What is your treatment plan?
5- what is the risk of rupture in this patient?
6- What would be the indication for intervention in his case?
7- Could you please mention at least one level 1 evidence that has been used to indicate the threshold for intervention?
Please make your answer as short and direct as possible
11 Comments
Hesham Rozza
A1- approach
family history ,any risk factors like smoking ,htn ,hyperlipidemia
any cardiac condition
A2-gemeral examination for vitals signs
examination of the abdomen for amy tenderness ,distension ,echymosis
ll examination for distal pulse and crt and check if there is pop aneurysm
A3-labs
routine (cbc-creat level- coagulation ) lipid profile
ecg-echo -pulmonary function test
imaging
CTA for anatomical assessment of ameurysm
A4-as size is 4.6 so start with lifestyle modification
and follow up us every 6 months
A5 less than 5 %
A6 symptomatic AAA
rapid increase in size more than 1 cm per year
leakage
A7uk small aneurysm trail
A1- Age, past medical history and associated co-morbidities, family history, history of back and abdominal pain, and any previous lap investigations done.
A2- Vitals, abdominal examination to assess guardians,
A3- CTA
A4- treatment plan?
Risk factor control.
statins and aspirin.
exercise and diet improvement.
A5- Less than 2%
A6- the indication for intervention case?
• AAA size ≥5.5 cm
• growth of more than 1cm per year
• leakage and/or embolic events
A7- NICE guideline
1- Please indicate How would you approach his history?
I will ask about age, past medical history, (especially HTN, and cardiac state), family history of any aneurysm or sudden death, any investigations done especially lipid profile. history of back or abdominal pain.
2- How would you perform clinical examination?
abdominal examination including inspection of any pulsatile mass, palpation of the aneurysm pulsation and size, auscultation of aneurysm area.
3- what investigation would you request?
I will ask for CTA
4- What is your treatment plan?
If less than 5.5 cm, I will recommend statins and aspirin and encourage exercise and follow up by US every 6 months.
5- what is the risk of rupture in this patient?
low risk (about 2%)
6- What would be the indication for intervention in his case?
If expanding 10 or more ml/year or reach 5.5 cm on follow up.
7- Could you please mention at least one level 1 evidence that has been used to indicate the threshold for intervention?
NICE and SVS guidelines, this is a consensus.
1- Please indicate How would you approach his history?
present history : any other associated symptoms
past history : any medical diseases or surgical history
family history : 1st degree relatives
2- How would you perform clinical examination?
abdominal examination to exclude tenderness guarding
peripheral examination to exclude pop aneurysm , distal embolisation , distal pulse
3- what investigation would you request?
full labs including lipid profile
4- What is your treatment plan?
no treatment for aneurysm
only cardiovascular risk control ( antiplatelet , statin , blood pressure control , stop smoking )
5- what is the risk of rupture in this patient?
less than 2%
6- What would be the indication for intervention in his case?
rapid growth more than 10mm per year
saccular aneurysm
symptomatic erosion of the vertebrae
7- Could you please mention at least one level 1 evidence that has been used to indicate the threshold for intervention? UK small aneurysm trial
Please make your answer as short and direct as possible
Personal history : age , marital status, work, smoking , fitness
Family history : other family members suffering from aneurysm
Past history : DM,HTN,dyslipedemia,COPD,nutrional status
Medication history
Present history : Ask about symptoms (pain, pulsatile mass) and analysis of onset of pain, timing, duration , radiation
evaluating Risk factors: smoking, HTN, family history.
Evaluating Comorbidities (heart, lungs, kidneys)which determine the fitness for surgery.
A2- clinical examination? • general :Vitals. • local :Abdominal pulsatile mass in supine and praying positions. • associated :Peripheral pulses and popliteal aneurysm.
A3- investigation to request? • imaging for anatomy :CTA abdomen/pelvis with 1 ml slices. • labs :CBC, U&E, coag, lipids, blood glucose, albumin. • for fitness :ECG, echo, lung function,.
A4- treatment plan?
Risk factor control.
life Style modification and regular exercise
surveillance → Repeated scan every 6 months as patient has AAA size <5.5 cm + asymptomatic picture
A5- the risk of rupture ? About 1% per year for 4.8 cm.
A6- the indication for intervention case? • AAA size ≥5.5 cm • Rapid growth →> 1 cm per year • Symptoms and complications → leakage, embolic events, Aorto caval fistula,
A7- level 1 evidence that has been used to indicate the threshold for intervention ? UK Small Aneurysm Trial supports 5.5 cm threshold.
A1
Personal history : age , marital status, work, smoking , fitness
Family history : other family members suffering from aneurysm
Past history : Dm,htn,dyslipedemia,copd,nutrional status
Medication history
Present history : analysis of onset of pain, timing, duration , radiation
…
A2..
I will exam the abdomin by inspection
of any visible epigastric pulsations and by palpation of any epigastric pulsating mass
Examination of the abdomin while the patient is in praying position is important to role out any transmitted epigastric pulsation
I will feel ll pulsation
…..
A3.. I will ask
Cbc
Pt ptt inr
Urea
Creat
Echo
Pulmonary stress test
…..
A4..
The plan of treatment is conservative management and smoking cessation ,regular exercise, libidlowering agents, controle of blood pressure strictly using B blokersand ACEI drugs
Regular follow up duplex US every 6 months
…..
A5 ..
according to meta analysis done to determine the risk of aneurysm al rupture the rupture risk of an aneurysm of 0.5CM WITH IS 6 months
Is it is symptomatic aneurysm giving symptoms of GIT, Renal or venous compression
…….
A6
Indicated for surgical intervention
1- growth > 1 cm per year
2-leakage
3- further embolic manifestations
4- Aorto caval fistula
……
A7
Data from UK small aneurysm trial and ADAM trial support the evidence of 5.5 CM aneurysm size as a threshold for intervention in men
Q1
Personal history : age , marital status, work, smoking , fitness
Family history : other family members suffering from aneurysm
Past history : Dm,htn,dyslipedemia,copd,nutrional status
Medication history
Present history : analysis of onset of pain, timing, duration
Q2
General exam ( pulse-BP-RR)
Abd exam : tenderness-rigidity- pulse or bruit
Peripheral arterial exam: axillary , femoral, pop
Q3
Basic ( cbc-pt-alt-ast)
Renal function creat urea creatine clearance
Liver albumin ast clotting time
Ecg echo stress echo
Pulm function test
Q4 size of 4.8 cm run with conservative technique us / 1 year
Stop smoking
Statin therapy
Anti plt
Control DM
Exercise
Healthy life style
Q5
Risk of rupture at this pt ,5 to 5 %
Q6
Indicated for surgical intervention
1- growth > 1 cm per year
2-leakage
3- further embolic manifestations
4- Aorto caval fistula
Q7 https://doi.org/10.1016/j.ejvs.2019.12.024
A1:
Family history
History of the complaint which is pain including nature of pain onset course duration and to differentiate the pain from spine problem together with associated complaints such as syncopal attacks git symtoms claudication any history of previous investigation
History of medical diseases HTN DM IHD SMOKING DYSLIPIDEMIA renal disease and history of medications together with previous surgery and PAD should ask for daily activity and his exercise tolerance to evaluate his CP function
A2:
General exam.
Bl pr both sides HR for rupture or leak cardiac chest exam for preop assessment periph pulsations as baseline and for embolic events
Local exam.
Abdomial inspection
for pulsation or bruises arround umblicus or flanks scars hernias stomas
Palpation of the aneurysm superficial for tenderness or guarding
A3:
Labs
Cbc cross matching and grouping KFT LFT ECHO ECG PFT INR
CPET non invasive testing of CPF
Anesthesia for fitness for op
Imaging
PAUS
CTA for size and anatomical considerations with decision making and planning along with access vessels and complete thoraco abd assessment
A4:
Control of risk factors smoking cessation anti htn statins
PAUS follow up every 6 months if it is not ruptured
OSR vs EVAR only in complicated AAA
EVARwould be preferred in case of ruptured infrarenal AAA
A5:
Risk of rupture in 4.8 aneurysm is arround 5%
A6:
Rupture would be the indication regarding the back pain but another indications are dissection leaking lower limb ALI
A7:
Ptns with ruptured AAA with favorable anatomy should be treated with EVAR
1 Hx taking in terms of risk factors as smoking , HTN, family Hx of AAA or peripherap aneurysm, personal Hx of peripheral aneurysm. whether the Pt has any sympotoms of abdominal pain or constipation / asymptomatic. Degree of his physical fitness
2 general examination as BP measurement , abdominal exam: palpation for any tenderness , examination of peripheral pulses including Pop A for ass peripheral aneurysm
3 inv shall include CBC, S crt, ECG- echo if indicated, abd USS for assessing size of aneurysm and its followup.
4 Pt needs BMD for risk management as smoking cessation, BP control , statin and anti-platelet as well as followup for size of aneurysm using USS every year.
5 risk of rupture is less than 5% in aneurysm between 4-5 cm as size is the strongest predictor of rupture
6 if there is size progression of more than 1 cm , symptomatic AAA or size exceeding 5.5 cm
7 Avishay DM, Reimon JD. Abdominal Aortic Repair. [Updated 2024 Jan 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554573/
A1..for this patient I will ask him about
History of smoking as smoking alone has a3.5folds of increased risk of AAA
Medical history of hypertension,hyperlipidemia are important risk factors
Family history of first degree relatives who had been diagnosed as AAA patient before
History of daily activities and life style
History of symptoms of urinary incontinence or loin pain and history of GIT upsets as dyspepsia and vomiting
A2..
For this patient I will exam the bdomine by inspection of any visible epigastric pulsations and by palpation of any epigastric pulsating mass
Examination of the abdomine while the patient is in praying position is important to role out any transmitted epigastric pulsation
A3.. I will ask for abdominal duplex US follow up every 6 months to follow up the progression of aneurysm size
A4..
The plan of treatment is conservative management and will be directed toward risk factors controle as smoking cessation ,regular exercise, libidlowering agents, controle of blood pressure strictly using B blokersand ACEI drugs
Regular follow up duplex US every 6 months
A5 ..
according to meta analysis done to determine the risk of aneurysm al rupture the rupture risk of an aneurysm of 0.5CM WITH IS 6 months
Is it is symptomatic aneurysm giving symptoms of GIT, Renal or venous compression
A7…
Data from UK small aneurysm trial and ADAM trial support the evidence of 5.5 CM aneurysm size as a threshold for intervention in men
A1- approach
family history ,any risk factors like smoking ,htn ,hyperlipidemia
any cardiac condition
A2-gemeral examination for vitals signs
examination of the abdomen for amy tenderness ,distension ,echymosis
ll examination for distal pulse and crt and check if there is pop aneurysm
A3-labs
routine (cbc-creat level- coagulation ) lipid profile
ecg-echo -pulmonary function test
imaging
CTA for anatomical assessment of ameurysm
A4-as size is 4.6 so start with lifestyle modification
and follow up us every 6 months
A5 less than 5 %
A6 symptomatic AAA
rapid increase in size more than 1 cm per year
leakage
A7uk small aneurysm trail
A1- Age, past medical history and associated co-morbidities, family history, history of back and abdominal pain, and any previous lap investigations done.
A2- Vitals, abdominal examination to assess guardians,
A3- CTA
A4- treatment plan?
A5- Less than 2%
A6- the indication for intervention case?
• AAA size ≥5.5 cm
• growth of more than 1cm per year
• leakage and/or embolic events
A7- NICE guideline
1- Please indicate How would you approach his history?
I will ask about age, past medical history, (especially HTN, and cardiac state), family history of any aneurysm or sudden death, any investigations done especially lipid profile. history of back or abdominal pain.
2- How would you perform clinical examination?
abdominal examination including inspection of any pulsatile mass, palpation of the aneurysm pulsation and size, auscultation of aneurysm area.
3- what investigation would you request?
I will ask for CTA
4- What is your treatment plan?
If less than 5.5 cm, I will recommend statins and aspirin and encourage exercise and follow up by US every 6 months.
5- what is the risk of rupture in this patient?
low risk (about 2%)
6- What would be the indication for intervention in his case?
If expanding 10 or more ml/year or reach 5.5 cm on follow up.
7- Could you please mention at least one level 1 evidence that has been used to indicate the threshold for intervention?
NICE and SVS guidelines, this is a consensus.
1- Please indicate How would you approach his history?
present history : any other associated symptoms
past history : any medical diseases or surgical history
family history : 1st degree relatives
2- How would you perform clinical examination?
abdominal examination to exclude tenderness guarding
peripheral examination to exclude pop aneurysm , distal embolisation , distal pulse
3- what investigation would you request?
full labs including lipid profile
4- What is your treatment plan?
no treatment for aneurysm
only cardiovascular risk control ( antiplatelet , statin , blood pressure control , stop smoking )
5- what is the risk of rupture in this patient?
less than 2%
6- What would be the indication for intervention in his case?
rapid growth more than 10mm per year
saccular aneurysm
symptomatic erosion of the vertebrae
7- Could you please mention at least one level 1 evidence that has been used to indicate the threshold for intervention?
UK small aneurysm trial
Please make your answer as short and direct as possible
A1- approach of history?
A2- clinical examination?
• general :Vitals.
• local :Abdominal pulsatile mass in supine and praying positions.
• associated :Peripheral pulses and popliteal aneurysm.
A3- investigation to request?
• imaging for anatomy :CTA abdomen/pelvis with 1 ml slices.
• labs :CBC, U&E, coag, lipids, blood glucose, albumin.
• for fitness :ECG, echo, lung function,.
A4- treatment plan?
A5- the risk of rupture ?
About 1% per year for 4.8 cm.
A6- the indication for intervention case?
• AAA size ≥5.5 cm
• Rapid growth →> 1 cm per year
• Symptoms and complications → leakage, embolic events, Aorto caval fistula,
A7- level 1 evidence that has been used to indicate the threshold for intervention ?
UK Small Aneurysm Trial supports 5.5 cm threshold.
1. History:
• Ask about symptoms (pain, pulsatile mass).
• Risk factors: smoking, HTN, family history.
• Comorbidities (heart, lungs, kidneys).
• Fitness for surgery.
2. Examination:
• Vitals.
• Abdominal exam for pulsatile mass.
• Peripheral pulses.
3. Investigations:
• CTA abdomen/pelvis.
• Bloods: CBC, U&E, coag, lipids.
• ECG ± echo.
4. Plan:
• Size <5.5 cm + asymptomatic → surveillance.
• Risk factor control.
• Repeat scan in 6-12 months.
5. Rupture Risk:
• ~1%/year for 4.8 cm.
6. Intervention Indications:
• ≥5.5 cm
• Rapid growth
• Symptoms
7. Evidence:
• UK Small Aneurysm Trial – supports 5.5 cm threshold.
A1
Personal history : age , marital status, work, smoking , fitness
Family history : other family members suffering from aneurysm
Past history : Dm,htn,dyslipedemia,copd,nutrional status
Medication history
Present history : analysis of onset of pain, timing, duration , radiation
…
A2..
I will exam the abdomin by inspection
of any visible epigastric pulsations and by palpation of any epigastric pulsating mass
Examination of the abdomin while the patient is in praying position is important to role out any transmitted epigastric pulsation
I will feel ll pulsation
…..
A3.. I will ask
Cbc
Pt ptt inr
Urea
Creat
Echo
Pulmonary stress test
…..
A4..
The plan of treatment is conservative management and smoking cessation ,regular exercise, libidlowering agents, controle of blood pressure strictly using B blokersand ACEI drugs
Regular follow up duplex US every 6 months
…..
A5 ..
according to meta analysis done to determine the risk of aneurysm al rupture the rupture risk of an aneurysm of 0.5CM WITH IS 6 months
Is it is symptomatic aneurysm giving symptoms of GIT, Renal or venous compression
…….
A6
Indicated for surgical intervention
1- growth > 1 cm per year
2-leakage
3- further embolic manifestations
4- Aorto caval fistula
……
A7
Data from UK small aneurysm trial and ADAM trial support the evidence of 5.5 CM aneurysm size as a threshold for intervention in men
Q1
Personal history : age , marital status, work, smoking , fitness
Family history : other family members suffering from aneurysm
Past history : Dm,htn,dyslipedemia,copd,nutrional status
Medication history
Present history : analysis of onset of pain, timing, duration
Q2
General exam ( pulse-BP-RR)
Abd exam : tenderness-rigidity- pulse or bruit
Peripheral arterial exam: axillary , femoral, pop
Q3
Basic ( cbc-pt-alt-ast)
Renal function creat urea creatine clearance
Liver albumin ast clotting time
Ecg echo stress echo
Pulm function test
Q4 size of 4.8 cm run with conservative technique us / 1 year
Stop smoking
Statin therapy
Anti plt
Control DM
Exercise
Healthy life style
Q5
Risk of rupture at this pt ,5 to 5 %
Q6
Indicated for surgical intervention
1- growth > 1 cm per year
2-leakage
3- further embolic manifestations
4- Aorto caval fistula
Q7
https://doi.org/10.1016/j.ejvs.2019.12.024
A1:
Family history
History of the complaint which is pain including nature of pain onset course duration and to differentiate the pain from spine problem together with associated complaints such as syncopal attacks git symtoms claudication any history of previous investigation
History of medical diseases HTN DM IHD SMOKING DYSLIPIDEMIA renal disease and history of medications together with previous surgery and PAD should ask for daily activity and his exercise tolerance to evaluate his CP function
A2:
General exam.
Bl pr both sides HR for rupture or leak cardiac chest exam for preop assessment periph pulsations as baseline and for embolic events
Local exam.
Abdomial inspection
for pulsation or bruises arround umblicus or flanks scars hernias stomas
Palpation of the aneurysm superficial for tenderness or guarding
A3:
Labs
Cbc cross matching and grouping KFT LFT ECHO ECG PFT INR
CPET non invasive testing of CPF
Anesthesia for fitness for op
Imaging
PAUS
CTA for size and anatomical considerations with decision making and planning along with access vessels and complete thoraco abd assessment
A4:
Control of risk factors smoking cessation anti htn statins
PAUS follow up every 6 months if it is not ruptured
OSR vs EVAR only in complicated AAA
EVARwould be preferred in case of ruptured infrarenal AAA
A5:
Risk of rupture in 4.8 aneurysm is arround 5%
A6:
Rupture would be the indication regarding the back pain but another indications are dissection leaking lower limb ALI
A7:
Ptns with ruptured AAA with favorable anatomy should be treated with EVAR
1 Hx taking in terms of risk factors as smoking , HTN, family Hx of AAA or peripherap aneurysm, personal Hx of peripheral aneurysm. whether the Pt has any sympotoms of abdominal pain or constipation / asymptomatic. Degree of his physical fitness
2 general examination as BP measurement , abdominal exam: palpation for any tenderness , examination of peripheral pulses including Pop A for ass peripheral aneurysm
3 inv shall include CBC, S crt, ECG- echo if indicated, abd USS for assessing size of aneurysm and its followup.
4 Pt needs BMD for risk management as smoking cessation, BP control , statin and anti-platelet as well as followup for size of aneurysm using USS every year.
5 risk of rupture is less than 5% in aneurysm between 4-5 cm as size is the strongest predictor of rupture
6 if there is size progression of more than 1 cm , symptomatic AAA or size exceeding 5.5 cm
7 Avishay DM, Reimon JD. Abdominal Aortic Repair. [Updated 2024 Jan 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554573/
A1..for this patient I will ask him about
History of smoking as smoking alone has a3.5folds of increased risk of AAA
Medical history of hypertension,hyperlipidemia are important risk factors
Family history of first degree relatives who had been diagnosed as AAA patient before
History of daily activities and life style
History of symptoms of urinary incontinence or loin pain and history of GIT upsets as dyspepsia and vomiting
A2..
For this patient I will exam the bdomine by inspection of any visible epigastric pulsations and by palpation of any epigastric pulsating mass
Examination of the abdomine while the patient is in praying position is important to role out any transmitted epigastric pulsation
A3.. I will ask for abdominal duplex US follow up every 6 months to follow up the progression of aneurysm size
A4..
The plan of treatment is conservative management and will be directed toward risk factors controle as smoking cessation ,regular exercise, libidlowering agents, controle of blood pressure strictly using B blokersand ACEI drugs
Regular follow up duplex US every 6 months
A5 ..
according to meta analysis done to determine the risk of aneurysm al rupture the rupture risk of an aneurysm of 0.5CM WITH IS 6 months
Is it is symptomatic aneurysm giving symptoms of GIT, Renal or venous compression
A7…
Data from UK small aneurysm trial and ADAM trial support the evidence of 5.5 CM aneurysm size as a threshold for intervention in men