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Wave 2: Module 3: Aortic Week 6 – Case 1
•82 Male is referred to you with incidental finding of 6.6 cm AAA detected in CT abdomen for an attack of diverticular disease 2/12.
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•He has a back ground of: HPN, DM and diverticular disease, he is an ex smoker. He underwent laparotomy after trauma 15 years undergoing splenectomy and small bowel repair . He has no family history of aneurysms . He is leading a sedentary life and uses his car for most of commutes. He can walk 300 meters before he gets short of breath.
•Regular meds Ca channel blocker and metformin .
•Examination : BMI 38 ,mid line laparotomy scar . Palpable non tender aneurysm palpable distal pulses . No popliteal aneurysms bilaterally.
•The CT is a portal phase Ct from level of diaphragm to Groins.
•Bloods: Hb 14, eGFR 70 HBA1c 7
•Echo showed reduced EF of 45 % with left ventricular strain and normal valves
•CPET AT 13 mlO2/kg/min with peak AT 18 mlO2/kg/min
•Spirometry – FEV1 (80%)
•Rockwood Clinical Frailty Score: 3
•reviewed by vascular anaesthetist : Fit for intervention (endovascular ) High risk of open.
| Thoracic Aorta | normal thoracic aorta | Patent subclavian artery bilaterally | ||
| Abdominal aorta | Proximal Landing zone 24 mm l . 25 mm above CA Aortic bifurcation 28 mm | Distal Rt CIA landing zone 16 mm ( 2 cm length) | Distal Lt CIA landing zone 12 mm ( 2 cm length)L | |
| Access | RT CFA 8 mm . Mild post wall atheroma | Rt EIA 9 mm minimal tortuosity | LT CFA 8 mm .moderate post wall atheroma 9 (60 % stenosis) | Lt EIA 9 mm minimal tortuosity |
| L | IVD | CLOCK | ||
| CA | 0 | 24 | 12 | 6 mm |
| SMA | 19 | 26 | 1230 | 7 mm |
| RRA | 24 | 28 | 1030 | 6 mm single artery |
| LRA | 27 | 28 | 0300 | 5 mm single artery |
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•Q1: The patient is with you in the clinic now, explain the key history and examination points
•Q2: What are your next steps and explain he rationale for each step ?
. Q3 : The patient came back to see you after undergoing the tests . Based on the data and the imaging finding explain your discussion with the patient regarding options and what evidence you have to support your decision making .
•Q4: Explain with evidence your approach and plan
•Q 5 :what is your plan for device and why (open/ FEVAR, BEVAR , T branch , ChEVAR). Any evidence to choose one approach versus the other ?
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A1
History
Analysis of complain
Like abd pain , gi bleeding
Bowel habits
As he incidentally discovered TAAA
Concentrate on dm htn ihd ckd dislipidemia
Chest problems
Social habits like smoking alcohol
Fhx
Pshx laparotomy
Medication
.
Examination
Equal peripheral pulse
Abd mass transmeted pulse
Expansility
Tenderness
Scar
………
A2
Next
Cta
From descending aorta till biforcation with 0.5 mm cuts axial and sagital
Complete pt invs life lung function
Fitness cardiac state
…………..
A3 and 4 5
Option OSR or Endo repair either by FEVAR or BEVAR or CHEVAR
But here as pt condition and abd previous surgery and IVD 24 and need landing zone supra renal and preserving of vesral vesseles so FEVAR will be optimal for him
Supported by UK compass trial
And eves guidelines 2024
Q1
History :
Personal H of smoking,alcholism,fatty diet
Past H of DM,Htn,IHD
Family H of aneurysm
Present H of any complain ,back pain, pressure symptoms
Examination
General : vitals
Local : abd, respiratory, peripheral
Q2
Ct angiography for aorta starting from ascending till bifurcation
With ,5 mm cuts axial and sagital view
Lap : cbc-pt – creat- alt – albumin
Echo,CPET
Q3
Diameter 6.5 cm has risk of rupture exceeding 67.5 %
So interference is a must
In this pt with poor fitness and hostile abdomen EVAR is prefered ( ESVS guidelines 2024)
Q4 Q5
As IVD less than 30 mm FEVAR is preferred than BEVAR & chimney
( ESVS guidelines 2024
A1:the key history and examination points
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A2:next steps and rationale
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A3 : decision making and explanation
Diameter 6.5 cm has risk of rupture exceeding 67.5 % So interference is a mandatory
Options for juxta renal AAA are ……
1- OSR with supra celiac clamping+visceral and renal revascularization with branched graft or isolated islands or carrel patch
2- endovascular repair( FEVAR -BEVAR- ChEVAR)
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A4: approach and explanation
because the patient has a complex AAA and a history of laparotomy and small bowel repair, endovascular repair (EVAR) is a be preferable option to avoid complications related to adhesions or bowel injury.
UK COMPASS trial showed comparable midterm mortality but safer perioperative period with FEVAR than OSR.
###########
A5 : plan and Explanation
According to the 2024 ESVS guidelines, if the infrarenal neck diameter (IVD) is less than 30 mm, FEVAR is preferred over BEVAR and CHEVAR, as it gives better control and more precise sealing in such anatomies.BEVAR is suitable for more than 30 to 40. Chimney is not recommended for guttering effect with high incidence of type1 endoleak so it’s preserved for emergency situations
Q1:
I would start by taking a full history of the abdominal pain — when it started, if it’s constant or colicky, any GI symptoms like nausea, vomiting, or change in bowel habits. I’d also ask about comorbidities like hypertension, diabetes, IHD, dyslipidemia, and smoking.
Family history is important too, especially for aneurysms or sudden deaths.
I’d also check surgical history — especially if there’s any previous laparotomy or bowel surgery.
On exam, I’d assess for any pulsatile abdominal mass and check peripheral pulses in the lower limbs.
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Q2:
Next step would be a CTA with 0.5 mm axial cuts covering the whole aorta down to the femoral arteries. Based on the CT findings and patient’s clinical data, we can discuss the management plan.
I’d also request cardiac and pulmonary function tests (like ECG, echo, and spirometry if needed), and full labs before deciding on intervention.
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Q3:
This patient has a 6.5 cm AAA, which puts him at high risk of rupture, so intervention is definitely indicated — it’s not something we can just watch or delay.
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Q4:
Since the patient has a complex AAA and a history of previous laparotomy and small bowel repair, endovascular repair (EVAR) would be preferable here to avoid complications related to adhesions or bowel injury.
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Q5:
According to the 2024 ESVS guidelines, if the infrarenal neck diameter (IVD) is less than 30 mm, FEVAR is preferred over BEVAR, as it gives better control and more precise sealing in such anatomies.
Q1:
full history of his abd . pain GI symptoms , hypertension , DM, IHD, Dyslipidemia , smoking
family history
surgical history
examination of the abdominal mass and peripheral pulsation
Q2:
next step will be CTA 0.5mm axial cut of the entire aorta to the feet the discussio of the patient data and ct findings and to proceed for the management plan
investigation cardiac and pulmonary function tests full labs
Q3:
the patient has AAA of 6.5 cm with high risk of rupture so intervention is mandatory
Q4:
the patient has a complex AAA with previous history of laparotomy and small bowel repair so endovascular will be preferable for him
Q5:
according to ESVS 2024 guidelines the IVD less than 30 mm so FEVAR is preferred than BEVAR
Q1
History :
Personal H of smoking,alcholism,fatty diet
Past H of DM,Htn,IHD
Family H of aneurysm
Present H of any complain ,back pain, pressure symptoms
Examination
General : vitals
Local : abd, respiratory, peripheral
Q2
Ct angiography for aorta starting from ascending till bifurcation
With ,5 mm cuts axial and sagital view
Lap : cbc-pt – creat- alt – albumin
Echo,CPET
Q3
Diameter 6.5 cm has risk of rupture exceeding 67.5 %
So interference is a must
In this pt with poor fitness and hostile abdomen EVAR is prefered ( ESVS guidelines 2024)
Q4 Q5
As IVD less than 30 mm FEVAR is preferred than BEVAR & chimney
( ESVS guidelines 2024)
A1:
History
Present history symtoms and signs with analysis of the complaints such as abd pain git bleeding bowel habits
and regarding he was incidentally discovered TAAA i will stress on his
past medical history HTN DM CKD IHD DYSLIPIDEMIA chest problems
Social history smoking drinking alcohol
Family history
Surgical history of ops
Medication and allergy history
Examination
Palpation intact and equal periph pulsation abdominal mass and tenderness
Bl pr HR
Inspection of the laparotomy scar
Auscultate air entry bilat
A2:
Next step would be CTA e 3d reconstruction with 0.5 mm axial cuts of the whole aorta down to fem bilat regarding his intact distal pulsation
MDT with the ptn data and ct findings
Planning for the management plans and options according to the anatomical considerations and in flow ouflow and access
completion of the investigations for the fittness including his pulm functions cardiac functions and labs and waiting for the patient preference to take the best decision
A3:A4:and A5
options for ttt of juxta renal AAA are OSR with supra celiac clamp and revascularization of vesceral and renal vessels or EV either FEVAR or BEVAR as long as CHEvar is not recommended for guttering effect with high incidence od type 1c endoleak
According to the ptn general condition and his fitness OSR would be associated with high morbidity and mortality so EV is of choice
according to the aortic diameter at the level of visceral vessles mainly RA are smaller than 30 mm so FEVAR would be preferable as the EVES 24 guidelines recommend FEVAR if IVD less than 30 mm and BEVAR for more than 30 to 40
Well done
Q1.key history and examination points
A.. for a patient with incidentally discovered AAA the main history important points are
Medical history of .. HTN, DM, Hyperlipidemia
Smoking history
Level of daily activities
Family history especially first degree relatives of AAA
Any previous abdominal surgery
For examination
General examination for patient vital signs are very important in case of suspected rupture AAA
Local examination of palpable abdominal masses , abdominal tenderness, distal pulsations
Q2.what next?
Answer..
For a6.6cm AAA it exceed the upper limit of at which rupture potentially is high so repaire of AAA is a must so I will arrange for CT aortogram from the heart to the toes to plan for repair
Then I will ask for assessing patient fitness by doing
CPET or stress ECHO
Liver and kidney function tests
CBC
Q3.
For this patient repair is the best here either OSR or by endovascular approach ..
Since the investigations show that the patient is frail to get her with previous abdominal surgery which will add to the complexity of the surgical operation so the best for the patient is endovascular repair
This is supported by UK COMPASS trial which showed comparable peri-operative and midterm mo
Midterm mortality but with safer peri-operative period than OSR
Answer q4
My approach will be endovascular repair by FEVAR as this is a case of complex neck AAA with involvement of renal vessels so the landing zones will be usually supra renal and the need for preservation of the visceral branches is a must so FEVAR is a suitable option in such a frail patient with relatively small IVD to not allow BEVAR
Answer q5
Due to the relatively small IVD FEVAR is better than BEVAR .
CHEVAR Is not favored in elective setting due to the high risk of endoleak development according to ESVS 2024 clinical practice guidelines
Well Done