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Clinical Crossroads | Clinician's Corner

A 66-Year-Old Man With an Abdominal Aortic Aneurysm Review of Screening and Treatment

Marc Schermerhorn, MD, Discussant
JAMA. 2009;302(18):2015-2022. doi:10.1001/jama.2009.1502.
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Published online

Ruptured abdominal aortic aneurysm (AAA) is a common cause of death. Abdominal aortic aneurysms tend to be asymptomatic until the time of rupture, which has a mortality rate of greater than 80%. Therefore, elective repair prior to rupture is preferred if life expectancy is reasonable and the risk of rupture outweighs the risk of repair. Mr F, a 66-year-old man with a 5.2-cm AAA, illustrates the issues surrounding monitoring and treating AAA. Risk factors for AAA include older age, male sex, smoking history, and a family history of AAA. Screening for AAA with ultrasound has been shown to prevent rupture, prevent AAA-related death, and be cost-effective. Risk factors for rupture include larger diameter, female sex, and smoking history. Endovascular repair has lower operative mortality and complications and has replaced standard open surgery in more than half of patients. However, long-term survival is similar after endovascular and open surgical repair. Those at risk of AAA who would benefit from repair should undergo screening.

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Figure 1. Mr F's Abdominal Ultrasound and Images From His Computed Tomographic Angiogram
Graphic Jump Location

A, The ultrasound shows the diameter of the infrarenal abdominal aortic aneurysm. B, Left slice shows the aneurysm and thrombus involving the infrarenal aorta. The aneurysm extends up to and possibly involves the main renal artery origins. The left slice illustrates the importance of appropriate plane when assessing diameter in the presence of angulation or tortuosity of the aorta. The horizontal line shows Mr F's aorta measurement as 5.2 cm, whereas the diagonal line shows the more accurate measurement, perpendicular to the center line of the aorta, as 4.6 cm. In both slices, a large accessory left renal artery arising from lower aorta involved in the aneurysm can be seen (yellow arrowheads). Note also the presence of 2 right renal arteries (black arrowhead). See interactive Figure of the computed tomographic angiogram here.

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Figure 2. Open and Endovascular Repair of Abdominal Aortic Aneurysm
Graphic Jump Location

A, With open repair, the abdomen is opened anteriorly (as shown) or from a lateral retroperitoneal approach. The aorta is clamped, preferably below the renal arteries, and the common iliac arteries are both clamped. The aneurysm sac is opened longitudinally; backbleeding lumbar arteries and the inferior mesenteric artery are typically suture-ligated. A prosthetic graft is then sutured in place proximally and distally. A bifurcated graft (shown) is used in more than half of cases with the distal anastomoses to the common iliac or, rarely, the common femoral arteries, as opposed to a straight tube graft sewn to the aortic bifurcation. The aneurysm sac is then closed over the graft to provide separation of the graft from the intestines. B, With endovascular repair, stiff wires are introduced through the common femoral arteries over which a fabric covered stent (stent-graft) is introduced. The proximal graft is positioned just below the renal arteries. The stent-graft is initially constrained in a low-profile state until deployment. A modular device is depicted in which a separate component for the left iliac limb is inserted through and overlaps with a docking limb on the main device. Ultimately, there is a seal zone in the normal infrarenal aorta and bilateral iliac arteries, thereby excluding the abdominal aortic aneurysm. See animation of surgical procedures here.




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A View Through the Smoke
Posted on October 27, 2009
Javier Ena, MD, MPH
Hospital Marina Baixa. Alicante. Spain
Conflict of Interest: None Declared
A major risk factor for the development of abdominal aortic aneurysm is smoking, and more than 90% of patients with such aneurysms have been smokers. After the cessation of smoking, the risk of developing an aneurysm declines each year, to approximately one thirtieth of the original risk [1]. The risk of rupture is low for aneurysms 5.5 cm or less in diameter, but above this threshold the risk increases markedly. After an aneurysm ruptures, only approximately 25% of patients reach the hospital alive, and only 10% reach the operating room alive [2]. Although blood pressure and lipids are currently well controlled, smoking is a significant risk factor for anerysm growth. I would send him to a smoking clinic and meanwhile check every 6 mo. the aneurysm size. If and when aneurysm size increases, an evaluation from a vascular surgeon will determine the feasibility of performing endovascular repair rather than open repair. An evaluation of pulmonary-function testing for chronic lung disease is also required [3]. Javier Ena, MD, MPH Dept. of Internal Medicine Hosp. Marina Baixa Alicante, Spain
No conflicts of interest reported.
1. Wilmink TBM, Quick CRG, Day NE. The association between cigarette smoking and abdominal aortic aneurysms. J Vasc Surg 1999;30:1099-1105.
2. Brown LC, Powell JT, UK Small Aneurysm Trial Participants. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. Ann Surg 1999;230:289-297.
3. Brown LC, Greenhalgh RM, Howell S, Powell JT, Thompson SG. Patient fitness and survival after abdominal aortic aneurysm repair in patients from the UK EVAR trials. Br J Surg 2007;94:709-716.
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