Week 1 – Case 1
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
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