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Wave 2: Module 3: Aortic Week 3 – Case 1
- May 12, 2025
- Posted by: admin
- Category: Uncategorized
55 yrs old male patient with past medical history smoking and hypertension, referred to your clinic with incidental finding of infrarenal AAA of 6 cm diameter in the CT with contract that was done to investigate kidney stones. By clinical examination the aneurysm in not tender. On reviewing the CT, the infrarenal neck is 22 mm in diameter, 3 cm long. CIA on both sides are aneurysm free and with diameter of 12 mm and with length of 3 cm on the right and 2.5 cm on the left. The patient is otherwise fit and well.
Q1: How will you approach this patient ?
Q2: If you are going to offer aneurysm repair, what type of repair is most suitable? Please support your answer with the evidence?
Q3: if the CT also showed horse shoe kidney, will that affect your management plan? Please justify your answer.
Q4: if you offered this patient standard infrarenal EVAR and on the final intra-operative angiogram you noticed type II endoleak, what is your next step?
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Q1 CTA and council the patient for repair, then preoperative fittness
Q2 due to expected long life i will offer OSR, as nice guidelines support OSR in such patients unless discovered to be unfit
Q3 yes it will affect my plan, i will offer EVAR as the horseshoe kidney makes the open repair complex
Q4 i will put the patient on routine follow-up imaging program, and i will intervene if there’s sac growth
A1- history : risk factors and family history
examination abdomen is pulsating and if tenderness
LL exam for vascularity and any peripheral aneurysm
inv labs routine
ecg -echo-CPET and pulmonary function test
imaging CTA
A2 as patient is young and cardiac fit I will go with open repair as it is more durable
according to ESVS guidelines
A3 I will convert to EVAR
as it is contraindicated in open repair
A4 type 2 endoleak is from IMA or lumbar backflow
it will treated conservatively
and follow up if sac is increasing in size more than 5 mm then we will go with embolization
q1 clinical assessment – surgical fitness- plan for intervention (CT aortography asssment)
q2 OSR as the patient is fit and young after exculsion of HOstile abdomen
q3 I will go for EVAR
q4 CTA 6m TO assess patency of the graft and endoleak
Q1 approach involve history , examples nation,investigation
History :
Family history
Personal h of smoking , working, fitness
Past h of DM , htn , hyperlipedemua,IHD , respiratory disorders
Present history : pain ,cource,radiation, association
Exam:
General pulse bp rr temp colourd
Local : abd , resp, HR, peripheral aneurysm
Investigation
Lap cbc pt creat albumin lipid profile
Radiological : ct abd pelvis
Ecg echo
Stess echo
Cpet
Q2
Young aged pt
Fit
Non hostile abd
Preferred for OST according to ESVS guidelines
Q3
Horseshoe kidney making abdomen hostile with risk of renal injury at open approach so EVAR is recommended as anatomy preserved , hostile abd
Q4
Endoleak type 2 mean refilling of aneurysmal sac retrograde by ima or lumbar
Ttt is conservative as there is no size expansion
If sac expand > 5 mm by 6 months or > 10 mm by 12 month
Indicated for clamping sac or coiling vessel
A1
Examin pt to confirm abd statues
Confirm dx
Full history taking
Ask Labs cbc liver fun kidney fun
Pt ptt inr
Assess fitness by echo , lung fun test
…..
A2 according to nice guidelines
Open repair
Pt young
Fit for open
Exclude hostile abd if there is previous abd surgeries or pathologist
……….
A3
Yes, I will go with evar
As kidney will be affected on clamping and declamping
……..
A4
Follow up imaging ct
If
Aneurysm growth more 5 mm over 6 m or resistance endo leak more 1 y
I go with intervention
• I would confirm the diagnosis, assess symptoms, review the full CT angiogram with 3D reconstruction, and assess the patient’s fitness for intervention (blood tests, ECG, echocardiogram, etc.). Then discuss treatment options with the patient.
• Standard infrarenal EVAR is most suitable. The neck is long (3 cm), straight, and non-aneurysmal (22 mm), and iliacs are suitable.
Evidence: NICE guidelines and trials like EVAR-1 support EVAR in anatomically suitable patients due to lower perioperative risk and faster recovery.
• Yes, a horseshoe kidney may affect planning. The isthmus may lie anterior to the aneurysm and could be injured during open repair. Also, aberrant renal arteries may arise from the aneurysm or iliacs — must be identified on pre-op imaging.
If EVAR is still anatomically feasible and renal supply preserved, it may be preferred.
• For an intraoperative Type II endoleak, I would observe and not intervene immediately.
Type II endoleaks often resolve spontaneously. Surveillance with duplex or CT is the standard approach unless sac expansion occurs later.
Q1: approach
⸻
Q2: type of repair with the evidence
• type:
For infrarenal AAA with a suitable neck anatomy (neck length 3 cm, diameter 22 mm, no aneurysm involvement in CIA), Endovascular Aneurysm Repair (EVAR) is often preferred because it is less invasive than open repair and associated with lower perioperative morbidity and mortality.
• Evidence:
⸻
Q3: horseshoe kidney and management plan
⸻
Q4: type II endoleak, next step
Thank you Dr Ahmed for the thorough answer. I have few comments:
Q2: given the young age and fittness, open repair should be the most suitable option as per NICE guidelines and the finding of the meta-analysis of the large 4 RCT (EVAR1, Over, Ace and Dutch trials) which showed open repair is more durable and EVAR loose the durability after 5-8 yrs due late aneurysm related mortality.
Q3: Horse shoe kidey make the abdomen hostile and as per ESVS guidline is a clear indication to offer EVAR not open repair.
Q4: Your answer is good but needs to be more clear regarding the Indication for intervention in type 2 endoleak which is sac expansion in serial imaging > 5mm over 6 months or > 10 mm over one year. It is not just the size but also over how long duration.
Recommendation: revise the ESVS and NICE guidelines for aortic aneurysm disease.
A1: Full history taking of patient and assessing fitness for surgery via ECHO, blood picture and ECG and advise urgency in taking decision as 6cm aneurysm has a high risk of rupture.
A2: If no abdominal pathology or previous laparoscopies, I will proceed with open surgical AAA repair according to NICE guidelines.
A3: Will have to go with EVAR according to guidelines
A4: Follow up every 6 months to assess sac expansion.
Well done Dr Akram, it is enforcement to what you said rather than a comment,
Good counselling
Good assessmnet of fitness and abdominal examination to rule out cause that can make the abdomen hostile.
Proper workup before open aortic surgery ( ECHO + Lung function test / or CPET)
Most type 2 resolve within 6 months and if they persist monitor rate of sac expansion, if no sac expansion continue monitoring.
A1..history taking of family history is important. History of abdominal pain or history of blood pressure controle
Abdominal examination for any pulsating mass with peripheral pulsation examination
Counselling the patient about the risk of rupture as the aneurysm is 6 cm
Asking for laboratory and imaging investigation for preparation for intervention
A2..
For this young age man and according to ESVS2024 guidelines for patients with long life expectancy OSR is better due to iti long durability
So I will offer him OSR
A3..
In presence of renal anomaly I think EVER will be favourable to avoid injury and interruption of ranal blood supply during dissection
A4..
Type II endoleak is retrograde flow through lumber vessels or IMA .. expectant management and conservative follow up may reveal disappearance of endoleak but persistent sac expansion and growth requires reintervention in the form of surgical ligation or laparoscopic clipping of sac feeding vessels or even coiling by endovascular means
Thank you Dr Mahdy for your answer. Thank you for highlighting the importance of excluding existence of other associated aneurysms e.g popliteal.
Please revise the ESVS guidelines regarding the indication for intervention in type 2 endoleak. I agree with your answer but more clarification is needed regarding when exactly you need to intervene. How much sac expansion over how long duration.
A1:
History including family operative medical disease and medications
Examination including the abd and peripheral pulsations bl pr
Investigation in the form of labs, tests and imaging for fittness for op ECG ECHO PFT
A2;:
OSR regarding his age general codition without abd pathology and co morbidities according to NICE and ESVS guidelines
A3:
Horse shoe kidney is an indication for EVAR in that case with suitable anatomy
A4:
Type II endoleak could be from lumber vv or IMA to be ttt with embolizationor surgical ligation of the IMA
Thank you Dr Mansy, I agree with all answers except for A4 needs more clarification. Please my comments to your colleagues regarding the same question. Also, revise the ESVS guidelines.
Q1:
full history and examination of distal pulsation for accompanied peripheral aneurysms
full investigation of full blood count and ECG and ECHO and CPET to assess the patient fitness for surgery
Q2:
OSR as patient is young and fit according to the NICE guidelines and the patient has no any abdominal pathology
Q3:
yes it will makes the OSR and control of the neck unsuitable
Q4:
type 2 endoleak means that there is retrograde flow from aortic side branches such as lumbar or IMA no intervention and needs follow up every 6 months to assess sac expansion
Thank you Dr Malek, happy with your A1 and A2.
A3 you need to be clear that you will ofer EVAR only.
A4, surveillance after EVAR is lifelong not just 6 months. Type 2 endoleak likely to resolve in 6 months but if it persists you need to monitor the sac expnsion and you need to clarify when to intervene if you see sac expansion. Please review my comments regarding this quesion in the other comments.