Abdominal Aortic Aneurysm - An Illustrated Narrative Review

12/1/2016
Abdominalaorticaneurysm:anillustratednarrativereview
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JournalofManipulativeandPhysiological
Therapeutics
Volume26,Issue3,March2003,Pages184195
Reviewoftheliterature
ColinMCrawford,BAppSc(Chiro)a,
JohnMarley,MD,MBChB,FRACGPd
,KristinHurtgenGrace,DCb,ErnestTalarico,BAppSc(Chiro)c ,
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doi:10.1016/S01614754(02)541117
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Abstract
Objective
Topresentadescriptivereviewofabdominalaorticaneurysm(AAA),includingareview
ofriskfactorsforandcasefindinginAAAforchiropractorsasprimarycontacthealthcare
practitioners.
Datasources
ClinicalandscientificliteratureidentifiedthroughvarioussourcesincludingMEDLINE
andcitationtracking.
Datasynthesis
Selectivenarrativereviewofrelevantliterature.
Results
AAAmaybeasymptomatichowever,backpainisacommonpresentingfeature.Risk
factorsincludemalegender,increasingage,cigarettesmoking,hypertension,chronic
obstructiveairwaydisease,claudication,andAAAinafirstdegreerelative.AAAshould
beconsideredinthedifferentialdiagnosisofolderwhitepatients,especiallymales,with
lowbackpain.EstimatedprevalenceforAAAsinoldermalesisintheorderof3%to5%
ruptureaccountsfor1.7%ofdeathsinmenaged65to75years.Electivesurgical
resectionofAAAs(priortorupture)offersalowoperativemortalityandgoodprognosis.
Conclusion
AAAshouldbeconsideredinthedifferentialdiagnosisofolderpatientspresentingwith
lowbackpainandthosewithriskfactorsforAAA.Chiropractors,asprimarycontact
healthcarepractitioners,havearesponsibilitytoreferpatientssuspectedofhavingAAA
forappropriateimagingand,whereindicated,vascularsurgicalopinion.
Keywords
AbdominalAneurysmChiropracticDiagnosisLowBackPain
Introduction
Lowbackpainisthemostcommondisablingmusculoskeletalsymptom.1Itisthesecond
mostcommonreasonpromptingpatientstoseekcarefromphysicians2andthe
http://www.sciencedirect.com/science/article/pii/S0161475402541117
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predominantpresentingcomplainttochiropractors.3and4Whilemostbackpainmaybe
ofmechanicalorigin,5carefulconsiderationmustbegiventoothercauses,especiallyin
anagingpopulation.Abdominalaorticaneurysm(AAA)isasignificantcauseoflowback
painandanimportantcauseofpreventabledeathintheolderperson.6Unlikecoronary
arterydiseaseandcerebrovasculardisease,theincidenceofAAAdramatically
increasedoverthe3decadesto19897andmayberising.AAAshouldthereforebe
consideredinthedifferentialdiagnosisofanolderpatientwithlowbackpain,particularly
inthosepatientswithknownriskfactorsforAAA.
Asignificantnumberoflivesmightbesavedifclinicians(especiallyrheumatologists
andorthopedicsurgeons)weremademoreawareofthispossibility.8Thequoteby
Duthie8appliesequallytochiropractorspurportingprimarycontactstatusasitdoesto
generalandspecialistmedicalpractitioners.Thisarticlereviewspathologyand
pathogenesis,epidemiologyandscreening,clinicalpresentationandassessment,
imaging,casefinding,9,10and11naturalhistory,andmanagementofAAA.
Discussion
Pathologyandpathogenesis
Ananeurysmisapathologic,irreversible12dilatationofasegmentofabloodvessel,13
causedbyacongenitaloracquiredweakness.14Aneurysmsareclassifiedaccordingto
theirsite,configuration,andetiology.14Seventyfivepercentofabdominalaortic
aneurysmsarelocatedbelowtherenalarteriesinthedistalabdominalaorta.13AAAsare
usuallyovoidswellingsaffectingtheentirecircumferenceofasegmentofthedistalaorta
andaredescribedasfusiform.14Asaccularaneurysmisaneccentric,localized
distendedsacaffectingonlypartofthecircumferenceofthearterialwall(Fig1).15
Fig1.
Cadavericspecimenoflowerabdominalaortaandiliacbifurcationdemonstratingsaccularaneurysms,the
lowerofwhichextends,asafusiformaneurysm,intorightproximaliliacartery.Horizontalmetalmarker
approximately2.5cmbelowintercristal(iliaccrest)line.A,PininlumbosacraldiskB,pininL45diskC,
pininL34diskD,pin(head)atoriginofinferiormesentericarteryE,pininL23disk.Rightrenalartery
(smallarrow).UnmarkedpininL12disk.Leftpsoasmuscle(arrow).Incidentally,thiscadaverhasan
anomalousinferiorvenacava(notshownhere).(Man,white,aged68yearscauseofdeath:congestive
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heartfailure,alsochronicobstructiveairwaydisease.)
Figureoptions
Atrueaneurysminvolvesall3layersofthevesselwall.Pseudoaneurysmsinvolve
disruptionoftheintimalandmediallayers,withthedilatationlinedbyadventitiaand
sometimesbyaperivascularclot.13Adissectinganeurysmis,infact,adissecting
hematomainwhichhemorrhageintothemediaseparatesthelayersofthevessel.14
Instudiesofanatomicalspecimens,thediameteroftheinferioraspectofthenormal
abdominalaortawaslessthan15mm(Fig2).Radiologicalstudieshavefoundthe
diameterofthenormalabdominalaortatomeasure,onaverage,19mm.16Despitethese
establishedstandards,aconsensusdefinitionofAAAdoesnotexist.17Anincreasein
diameterof50%isoneacceptedcriterionfordefininganabdominalaorticaneurysm.12
Otherdefinitionsincludeaninfrarenalaortameasurementof30mmormore17,18and19or
aratioofinfrarenaltosuprarenaldiametersgreaterthan1.5:1.17
Fig2.
Normallowerabdominalaorta,iliacbifurcation(arrow)andright(R)andleft(L)iliacarteriesinacadaveric
specimen(Man,white,aged68years).
Figureoptions
Traditionally,AAAshavebeenassociatedwithatheroscleroticdiseaseandfrequently
referredtoasatheroscleroticaneurysms.However,itappearsthatatherosclerotic
changesmaybesecondarytoabdominalaorticaneurysmsratherthanbeingprimary.7
EpidemiologicalcharacteristicsandgeneticriskfactorsaredifferentinpatientswithAAA
comparedtothosewithstenosingarterialdisease.20Thelowerabdominalaortadepends
ondiffusionofnutrientsfromtheaorticlumen,becausevasavasorumaredeficientinthis
partoftheaorta.12Impaireddiffusionthroughdamagedintima,atheroscleroticplaques
andoverlyingthrombi,andvesselwallvibrationmayfurtherweakentheaorticmediaand
facilitatethedevelopmentofinfrarenalabdominalaorticaneurysm.12and20
Histologically,theaneurysmalaorticwallcontainsinflammatoryinfiltrateand
inflammatorymediators,whichmaycontributetothedestructionandweakeningofthe
aorticmedia.InpatientsundergoingsurgeryforAAA,theaneurysmisconsideredtobe
inflammatoryinabout3%to10%ofcases.20and21Traditionally,inflammatory
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aneurysmshavebeenviewedasadistinctclinicalandpathologicalentitycausedbyan
autoimmuneresponsetocomponentsoftheaorticwall.20InflammatoryAAAsare
characterizedbyatriadofthickenedaneurysmwall,extensiveperianeurysmaland
retroperitonealfibrosis,anddenseadhesionsofadjacentabdominalorgans.21Intense
inflammatorycellinfiltrateoftenextendsbeyondtheaorticwallintosurrounding
tissues.20RecentevidencesuggeststhatalthoughinflammatoryAAAsarisefromthe
samestimuliresponsiblefornoninflammatoryAAAs,theyrepresentoneextremeofan
inflammatoryspectrum.21
Manyfactors,actingovertime,contributetothepathogenesisofabdominalaortic
aneurysm.Elastinandcollagenareimportantstructuralcomponentsoftheaorticwall.
Elastiniseasilystretchedandprovidestheelasticrecoiloflargearteries,whileaortic
collageniscoiledsuchthattheinitialloadintheaortaisbornebyelastin.Asthevessel
continuestostretch,collagenfibersbecomeloadbearing.Aorticcollagenhasatensile
strengthmorethan20timesgreaterthanthatofelastinbutcannotextendbeyondasmall
proportionofitsoriginallengthbeforestructuraldamageoccurs.Initially,destructionof
elastinshiftstheloadofpulsatilebloodflowintheloweraortafromelastintocollagen.
Partofthemarkedstiffnessorinelasticityofdilatedoraneurysmalvesselsisattributable
tothelossofelastin.Yearsofpulsatilebloodflowthroughthedegeneratedvesselwall
exacerbatetheprocess,andthecollageniscontinuouslyexposedtotheexpansileforce
ofintraluminalbloodpressure.Theextentofdilatationandsubsequentrupturedepends
onthepropertiesofthecollagenandtheneteffectofcollagendegradation,turnover,and
remodeling.20
FamilialclusteringofAAAsuggestsageneticbasistothisdisease.Inheriteddefectsin
elastinandcollagenmightweakentheaorticwall,orgeneticvariablesmayincrease
enzymaticdestructionofvesselwallconstituents.20BothXlinkedandautosomal
dominantmodesofinheritancehavebeensuggested.22and23
CertainheritablediseasesofconnectivetissuehaveanassociationwithAAA,including
MarfansyndromeandEhlersDanlossyndromes(EDS).Marfansyndromeresultsfroma
mutationinthegenethatcodesforfibrillin,afamilyofconnectivetissueproteinsthat
serveasscaffoldingforthedepositionofelastinduringembryonicdevelopment.This
geneticmutationweakenstheaorticmediaanddilatationoccurs,resultinginahigh
incidenceofdissectinganeurysms,especiallyintheascendingaorta.TheEDSarea
raregroupofdisorderscharacterizedbyhyperelasticityandfragilityoftheskin,joint
hypermobility,andableedingdiathesis.EDSIVisassociatedwithatendencyto
spontaneousruptureoflargearteries.24
CigarettesmokinghasbeenstronglyassociatedwiththepresenceofAAA,deathfrom
rupture,andaneurysmexpansionrates.Themechanismisthoughttobeenhancement
ofproteolyticenzymedegradationoftheaorticwallbygaseousandbloodborne
productsoftobaccocombustion.20and25Theonlyprophylacticadvicethatappears
usefuliscessationofsmoking.26
Hypertensionisassociatedwithincreasedprevalenceandincreasedriskofrupture.
Hypertensionmayberelateddirectlytopathogenesisormaymerelyexacerbatethe
effectofbloodflowforcesonanalreadyweakenedaorticwall.20Arecentstudyfounda
lowincidenceofAAAsinelderlypatientswithtreated,uncomplicatedhypertensionand
concludedthatuncomplicatedhypertensionbyitselfwasnotanindicationfor
screening.27
AAAisuncommonbefore50yearsofage.Normalagingisassociatedwithalterationsin
thestructureand,consequently,themechanicalpropertiesoftheaorticwall.Thus,the
agingaortamaybelessabletowithstandtheforceofpulsatilebloodflow,resultingin
aneurysmaldilatation.20
ThedifferentprocessesinvolvedinthepathogenesisofAAAareintegrated
diagrammaticallyinFigure3.Theirrelativeimportancemayvaryfromonepatientto
another.20
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Fig3.
Pathogenesisofabdominalaorticaneurysm.ReproducedwithpermissionoftheEditorsoftheBritish
JournalofSurgery.20
Figureoptions
Epidemiologyandriskfactors
AAAis10timesmorecommonin65to75yearoldmencomparedtowomenofthe
sameage.Thisisincontrasttothemaletofemaleratioforatheroscleroticdisease,
whichiscloserto2:1.ThegenderrelateddifferenceinAAAdiminishestoabout3:1inthe
85to89yearoldagegroup.25Theprevalenceofaneurysmsgreaterthan4.0cmin
diameterinmenagedbetween65and75yearsisapproximately3%.Otherstudieshave
estimatedtheprevalenceofunsuspectedaorticaneurysmtobe5.4%.28Studieshave
reportedprevalenceratesof12%to33%infirstdegreerelatives.12and17
Abdominalaorticaneurysm(withelectiverepairorrupture)isthe10thto13thleading
causeofdeathintheUnitedStates.7ThedeathrateforAAA(rupture)intheUnited
Kingdompeaksat65to75yearsofageruptureaccountsfor1.7%ofalldeathsinmenin
thisagegroupintheUnitedKingdom.DeathfromAAAinEnglandandWalesshoweda
progressiveandcontinuingincreaseovera30yearperiodto1988.25and29The
increasedprevalenceofaneurysmhasparalleledthepatternoftobaccoaddiction,which
roseduringtheperiod1916to1948acohorteffectwitha40yeartimelaghasbeen
suggestedtoexplainthisobservation.25Increasedawarenessofabdominalaortic
aneurysms,screeningprograms,andtheagingpopulationarealsothoughttohave
contributedtoanincreaseintheincidenceofasymptomaticAAAs.Inastudyinthe
UnitedStates,whitemenhadhigherageadjusteddeathratesforaorticaneurysmthan
blackmen.Theagespecificratesweresimilarorhigherinblackmenunderage65
years.Blackwomenhadhigherratesthanwhitewomenunderage65years,similar
ratesatages65to84years,andlowerratesabove85years.30
CorrelationbetweenhypertensionandcigarettesmokingandthedevelopmentofAAA
wasfoundinstudiesreviewedbyReillyandTilson.7However,asubstantialnumberof
patientswithouthypertensionorahistoryofsmokingdevelopabdominalaortic
aneurysms.7Thepresenceofchronicobstructivepulmonary(airway)disease,
independentofsmoking,wasfoundtobepredictiveofruptureofaorticaneurysm.31
ReillyandTilson7concludedthatfurtherresearchisneededtolookattheclinical
expressionofthediseaseandtheinterplayofenvironmentalfactors,suchassmoking,
againstabackgroundofdefinedgeneticrisk.Claudicationwastheonlycardiovascular
complicationindependentlyassociatedwiththepresenceofAAAinastudyof
predominantlywhitemenpresentingtoahypertensionclinic.27
Themeanbodymassindex(weightinkg/heightinm2)10inmenandwomenwith
aneurysmswasnotsignificantlygreaterthanthatofnormalsubjectsinanItalianstudy.32
However,aNorthAmericanstudyfoundheighttoberelatedtothepresenceofaortic
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aneurysmsandapositiveassociationbetweenbodyweightandaneurysms.33This
studydocumentedthestrongassociationofcardiovascularriskfactorsandmeasuresof
clinicalandsubclinicalatherosclerosis,cardiovasculardisease,andprevalenceof
aneurysms.
Clinicalpresentationandexamination
Abdominalaorticaneurysmisusuallyasymptomaticuntilruptureorsizedrawsthe
attentionofthepatientorphysiciantoit.25Afeelingoffullnessorpulsationsinthe
abdomenmaybeearlysymptoms.34Inonereviewof528patientswithaneurysms,91%
hadsymptomsattheirfirstpresentationthemostcommonsymptomsatfirst
presentationwereabdominalpainandbackache.Only48ofthe528patientsinthisstudy
werecompletelyasymptomatic,withananeurysmfoundatexaminationforanother
complaint.35TheclinicianshouldconsiderthepossibilityofruptureofanAAAinamale
patientovertheageof60yearswhopresentswithsuddenonsetbackand/orloinpain8
withshockand/orsyncope.12Inaddition,patientcharacteristicswhichmayraiseclinical
suspicionofAAAincludebeingacurrentsmokerorwithasignificantsmokinghistory,
increasedweight,ahistoryofmyocardialinfarction,6andclaudication.27Asdiscussed
above,astrongfamilialoccurrenceofAAAshouldalsoraisediagnosticsuspicion,as
shouldthepresenceofhypertension.7
Clinically,theabdominalaortamaybelocatedanteriorlyinthemidlinebetweenapoint
2.5cmabovethetranspyloricplaneandapointslightlyinferiorandalittletotheleftofthe
umbilicus.Thetranspyloricplaneisanimaginaryhorizontalplanelocatedmidway
betweenthexiphisternaljointandtheumbilicus.Theaorticbifurcationintothecommon
iliacarteriesoccursjusttotheleftofthemidpointofthelinejoiningthehighestpointsof
theiliaccrests(intercristalline)(Fig1,Fig2andFig6).36Appleberg12highlightstheneed
topalpatespecificallyforabdominalaneurysm.Theexaminationshouldbeconducted
withthesupinepatientskneesraisedandtheabdomenrelaxed.37Thetechnique
involvesdeepandcarefulpalpationwiththepalmsdown,totheleftofthemidline,
keepingthehandssteadyinonepositionuntiltheaorticpulseisfelt,andthencarefully
evaluatingthetransverseextentoftheexpansilepulsewiththepadsoftheindex
fingers.12and37Physicalfindingsmayincludeatender,38palpable,pulsatileabdominal
mass35withabdominalbruit.34
Itisimportanttorecognizethatabdominalpalpationforthedetectionofabdominalaortic
aneurysmshaslowoverallsensitivity(ie,highfalsenegatives).6Onestudy,thepurpose
ofwhichwasinteraliatodeterminetheaccuracyofphysicalexaminationinAAA
detection,6(p1753)foundthatabdominalpalpationdetectedonlyhalfof18previously
unsuspectedaneurysmsin201patients.Thisstudyfoundthatabdominalgirthwasan
importantfactorindetectingAAAbyphysicalexamination.NoAAAwasmissedon
palpationbythestudyteam,comprisingstaffinternists,whenthegirthwaslessthan100
cm.In109subjectswithagirthof100cmorgreater,only3of12AAAswerepalpable.6
FivepatientsinthisstudywithAAAswhohadadefinitepulsatilemassdetectedby
palpationhad,onchartreview,abdominalexaminationsrecordedasnegativebytheir
primarycarephysicians.Theauthorsofthisstudydidnotcommentspecificallyon
interexaminerorintraexaminerreliabilityofabdominalexaminationfindings.Alaterstudy
foundfairtogoodinterobservermeanpairagreementandkappascoresforthepresence
ornotofAAA.Itfoundhighsensitivityfordiagnosisofabdominalaorticaneurysmslarge
enoughtowarrantelectiveinterventioninpatientswhodidnothavealargeabdominal
girthandgoodsensitivityinpatientswithalargegirthiftheaortawaspalpable.37
Unusualclinicalpresentations
UnusualclinicalpresentationsofAAAmayresultfromchroniccontainedrupture,
inflammatoryaneurysm,aortovenousfistula,andatheroembolism.Thesemanifestations
maycomplicatesurgeryandraiseoperativemorbidityandmortality.38Achronic
containedrupturemay,inadditiontoabdominalorlowbackpain,causepressureeffects
resultinginjaundicefromcommonbileductcompressionorinureteralobstruction,
femoralneuropathy,orextensionofthehematomaintothefemoralsheath,simulatinga
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groinhernia.38
Socalledinflammatoryaneurysms(seecommentsabove)mayresultinadhesions
involvingstructuressuchastheduodenum,inferiorvenacava,andleftrenalvein.Two
thirdsormoreofpatientswithinflammatoryaneurysmsaresymptomaticatthetimeof
presentationcommonsymptomsincludeabdominal,flank,and/orbackpainanorexia
weightlossandelevatederythrocytesedimentationrate.21and38
AortocavalandaortorenalveinfistulasresultfromruptureofanAAAintotheinferiorvena
cavaortheleftrenalvein.Clinicalpresentationincludeshighoutputheartfailure,
cardiomegaly,apalpableabdominalmass,audiblecontinuousbruit,hypotension,
oliguria,andabdominalandbackpain.38
Infectedaneurysmsarerareandmayresultfromsuperimposedinfectionorarise
secondarilyfromaninfection.Clinically,infectedaneurysmsmaypresentwiththe
suddenappearanceofapulsatilemassorrecentenlargementofaknownAAAin
combinationwithfeverorrecentfebrileillness.38
Atheroembolismfromanabdominalaorticaneurysmto1orbothofthelowerextremities
isawelldocumentedoccurrence.38Thrombuswithinthelumenoftheaneurysmor
cholesteroldebrisfromwithintheintimaofthewallcanbethesourceofmacroembolior
microemboli,respectively.Macroembolismpresentswithsymptomsandsignsoflarge
vesselocclusionandsuddenischemiaofthelowerlimbs.Smallvesselocclusion
resultingfrommicroembolipresentsasslowlyevolvinglivedoreticularis,painfulcyanotic
toes,andpalpablepedalpulses.Microembolismhasbeentermedbluetoesyndrome
becauseofthecharacteristiccyanosisofthetoesifbothlowerextremitiesareinvolved,
anAAAorotheraorticsourceshouldbeconsidered.38
OtherunusualcomplicationsofAAAsincluderecurrentischemicmyelopathyand/or
paraparesis.Ischemicspinalcordlesionsmaypresentwithbladderincontinence,a
mixtureofupperandlowermotorneuronlowerlimbssigns,andpatchysensoryloss.39
Paraparesismayresultfromanteriorspinalarterysyndrome,whichpresentsasa
varyingdegreeofmuscleweaknessanddissociatedsensorylossofpainwithsparingof
proprioception.40
Imaging
Therearenumerousmodalitiesavailableforimagingtheaortaeachhasstrengthsand
weaknesses.Variationsinindividualcases,equipmentavailability,technicalexpertise,
andsurgeonpreferenceallinfluenceimagingmodalityselection.41
Abdominalaorticaneurysmsarefrequentlynotedonfrontal(anteriorposterior[AP])(Fig
4),lateral(Fig5),andobliquelowbackplainfilmradiographs.MostAAAsoccurbetween
therenalarteriesandtheiliacbifurcationthatis,betweentheL2andL4vertebrallevels,
respectively.Inthefrontal(AP)projection,anAAAisusuallyseenontheleftsideofthe
spineandappearsasasofttissuedensitydemarcatedbyathin,curvilinearrimof
continuousordiscontinuouscalcification.Onthelateralview,collimationmayprevent
theanteriormarginfrombeingvisualized.Attimesonthelateralview,theonlyindication
ofAAAmaybeahorizontallyorientedcalcifiedplaque.19Calcificationisnotedin55%to
85%ofAAAs41and42intheremainder,asofttissuedensitymaybeidentifiable.Erosion
oftheanteriormarginsofthevertebralbodies(Oppenheimererosions)maybenoted
withinflammatoryandsaccular(Fig1andFig6)aneurysmsandthoseinvolving
containedrupture.19and43
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Fig4.
Anteroposteriorlumbopelvic(APLP)plainfilmradiograph:Curvilinearrimofdiscontinuouscalcificationof
thewallofAAA(largearrows)maximumtransversediameter8.5cm.Bilateraliliacarterycalcification
(seenclearlyonrightsideonlysmallarrow).
Figureoptions
Fig5.
Laterallumbosacral(LATLS)plainfilmradiograph:Horizontallyorientedcalcifiedplaqueonthesuperior
marginofAAA(arrows)justanteriortotheL3vertebralbody.
Figureoptions
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Fig6.
Anteriorposterior(AP)radiographofcadavericspecimeninFigure1.A,PininlumbosacraldiskB,pinin
L45diskC,pininL34diskD,pin(head)inoriginofinferiormesentericarteryE,pininL23diskF,pin
inL12disk.Rightproximaliliacarteryaneurysm(smallarrows).Largerarrowatlevelofaorticbifurcation.
Figureoptions
Ultrasoundscanningiscurrentlythemostpracticalandaccuratewayofdetecting
abdominalaorticaneurysmsinlargenumbersofpeople17and44andhasbecomethe
mostcommonlyusedmethodofscreening.41,44,45and46Ultrasoundenablesdiagnostic
confirmation,evaluationofsize,andmonitoringofprogression.44Measurementsof
AAAsfromultrasoundcorrelatewithin3mmofsurgicalspecimens.41Diagnostic
ultrasoundmayshowthrombus(Fig7),periaorticabnormalities,dissections,andthe
cephalicandcaudalextentofthelesion.41Diagnosticlimitationsofultrasoundinclude
difficultiesimagingobesepatientsandthosewithabundantoverlyingbowelgas.41The
renalarteriescanonlyrarelybevisualizeddirectlyandinferencesregardingsuprarenal
extensionofanAAAcanonlybemadefromtherelationshipoftheaneurysmtothe
superiormesentericartery.41GrahamandChan44studiedultrasoundscreeningfor
clinicallyoccultAAAandconcludedthatthefalsenegativeresultsfortheultrasound
detectionofAAAswasprobablylow,suggestingthatultrasoundscanningwasa
sensitiveprocedureforthediagnosisofAAA.Thespecificityandpositivepredictivevalue
ofultrasoundhavebeenshowntobe100%,6andthus,thismodalityisoptimalfor
screeningandfollowupinnoncomplicatedcases.41ClinicalsuspicionofAAAshould
leadtoconfirmationwithultrasound.19
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Fig7.
UltrasoundofalargeAAA.ThetransversediameterofthisAAAmeasures7.91cmintraluminaldiameter
is4.73cm.Intraluminalclotisclearlyvisible.(CourtesyofSulzerVascutek,Australia.)
Figureoptions
Computedtomography(CT)accuratelydemonstratesthesizeandcraniocaudalextent
ofanabdominalaorticaneurysmandisusuallyabletodetectintraluminalthrombus.CT
alsoenablesvisualizationoftheretroperitoneum,allowingdetectionofaneurysmalleak,
ureteralobstruction,perianeurysmalfibrosis,andotherunusualcausesofabdominalor
backpain.41PostinfusionCTscansfacilitatedifferentiationofthepatentlumenofthe
aneurysmfromsurroundingintraluminalthrombus(Fig8).CTscanningisthemodalityof
choiceforpostsurgicalrepairevaluationofAAAs.41However,CTscanningofAAAs
requiresexposingthepatienttoionizingradiationandtheadministrationofcontrast
material.47
Fig8.
CTscanwithcontrastinthepatentlumen(smallarrow)ofatypicalAAAthrombus(largearrow).
Figureoptions
Themultiplanardisplaycapabilityofmagneticresonanceimaging(MRI)can
demonstratethefeaturesdiscussedabovewithouttheneedforcontrastitallows
accuratemeasurement,isolatesflowabnormalities,identifiesclot,andallows
assessmentofvisceralinvolvement.19MRIisnoninvasiveandreducestheneedfor
angiography(Fig9).MRImaybecontraindicatedinpatientsrequiringrespiratorsor
monitoringequipment.Gadoliniumenhancedmagneticresonanceangiography(MRA)
isavariationofstandardmagneticresonanceimaging,utilizingaparamagneticcontrast
agent.Thismodalityprovidesanatomicinformationforaorticreconstructivesurgery
withoutthecontrastrelatedrenaltoxicityorcatheterizationrelatedcomplications
attendingconventionalarteriography.48Further,theadvantagesofMRangiography
includethelackofionizingradiationandneedforiodinatedcontrastmaterialandits
abilitytoimagetheentireabdomenandpelvis,aswellasthethoraxandlower
extremitiesifnecessary.49
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Fig9.
MRIscansandaortogramsoflargeinfrarenalAAAina67yearoldman.A,Obliquecoronal2dimensional
(timeofflight)magneticresonance(MR)angiogramdemonstratesthewidestdimensionoftheAAA.B,
Threedimensional(maximumintensityprojection)MRangiogramreconstructedfrommultiple2
dimensionalsectionsshowstheAAAstartingbelowtherenalarteries(whitearrows)andextendinginto
bothiliacarteries(blackarrows).C,Conventionalaortogramhelpsconfirmtheiliacarteryextensionofthe
AAA.D,Targeted(maximumintensityprojection)imagehelpsconfirmnormalproximalrenalarteries
(arrows)reconstructedfrom2dimensionalMRangiograms.E,Conventionalaortogramhelpsconfirm
patentrenalarteries.ReproducedwithpermissionoftheEditorsofRadiologyandtheauthors.67
Figureoptions
Angiographyisusedtoevaluatethestateoftherenalarteriesandothervesselsinthe
iliacarterysysteminpatientswithAAA12(Fig9,CandE).Itisthegoldstandardfor
demonstratingvisceralbranchinvolvementandvascularanatomy.41However,
angiographymayunderdemonstratethesizeandextentofthethrombusfilled
aneurysm,asonlythelumenisdemonstrated.41Theuseofangiographymayalterthe
surgicalapproachutilizedinupto25%ofcases.19
Naturalhistory
MostAAAscontinuetoenlargeprogressively.12Smallaneurysmsincreaseintransverse
diameterbyupto5mmperyear31and50theanteroposteriordiameterincreasesbyan
averageof2.2mmperyear.31Largeaneurysmsexpandmorerapidlythansmaller
ones.12and50Theriskofruptureincreasessignificantlyasthesizeoftheaneurysm
increases,witha43%riskofrupturewithin12monthsofaneurysmsgreaterthan6cm.51
Patientswithaneurysmslessthan5cmalsoruntheriskofrupturein2%to32.9%of
cases.12
Thenonoperativemortalityofrupturedabdominalaorticaneurysmis100%.The
operativemortalityofrupturedaneurysmisaround50%survivalprospectsare
enhancedbyadmittancetoaspecialistsurgicalunit(ie,bysurgicalskill)andrelate
inverselytoincreasingseverityanddurationofpreoperativehypotension.25Ina
retrospectivereviewof528cases,themortalityrateforacutepresentations,asopposed
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torupture,was19%.35Overthe3decadesto1988,themortalityforelectiveAAA
surgeryprogressivelyfelltolessthan3%.25Somecentersclaimanelectivemortalityas
lowas1.4%.25Ageisnotanindicationtoforegosurgerysafeaneurysmrepairis
possibleformanypatientsover80yearsofage.52
Roleofscreening
Screeningisthepresumptiveidentificationofunrecognizeddiseaseordefectbythe
applicationoftests,examinations,orotherprocedureswhichcanbeappliedrapidly.53
Toqualifyasatargetforascreeningprogram,adisorderneedstobefairlyprevalentand
detectablebyteststhatareinexpensive,accurate,acceptabletopatients,andtreatable
withlowrisk.54Screeningproceduresalsoneedtobebothsensitiveand
specific.44Sensitivityreferstopositivityindisease,55(p81)ortheproportionofpatients
withthetargetdisorderwhohaveapositivetest.Specificityreferstotheabilityofatestto
correctlyidentifythosepatientswithoutthetargetdisorder(ie,negativityinhealth).
55(p82)
Inonestudyofpatientswithgirthmeasurementoflessthan100cm,noAAAwasmissed
onabdominalpalpation,6suggestinghighsensitivityofabdominalpalpationinthisgroup.
Thisdegreeofsensitivitywasnotobtainedwithroutineexaminations,andthestudy
concludedthattheexaminationneededtobedirectedspecificallytowardAAAdetection.
ThecautiongivenbyAppleberg12isworthyofreiteration,namely,theneedfordeepand
carefulpalpationspecificallyforAAA(seeabove).IntheOxfordScreeningProgramme
forAAAinmenaged65to74years,thesensitivityandpositivepredictivevalueof
abdominalpalpationforepigastricand/orinfraumbilicalmidlinepulsationswerepoor,
whilespecificitywasover90%.28Overall,abdominalpalpationhasbeenreportedto
havelowsensitivityindetectingAAA.6and56Exceptinasmallnumberofpatients,
therefore,abdominalpalpationfailstomeettherequirementsforascreeningtool.
Ontheotherhand,ultrasoundscreeningmeetsthecriteriatobeconsideredan
acceptablescreeningtestforthedetectionofAAA,includingacceptablesensitivityand
specificity.6and44Arecentprospectivestudysupportedannualscreeningusingserial
ultrasoundforsmallaneurysms(2.5to3.9cm)and6monthscreeningforthose
measuring4.0cmorgreater.50Arguably,withhighmortalityratesassociatedwith
surgicalrepairofrupturedAAAsandthelowmortalityrateassociatedwithelectiverepair
ofaneurysms,obesemalesovertheageof55yearswithhypertension,coronaryartery
disease,cerebrovasculardisease,orperipheralarterydisease56shouldberoutinely
screenedwithultrasound.44Patients,especiallymenwithchronicobstructiveairway
disease,orthosewhoarefirstdegreerelativesofaknownaneurysmpatient,shouldalso
undergoscreening.26and54Assmokingisasignificantriskfactor,thescreeningof
smokersinthe65to80yearoldagegroupmayalsoconstituteacosteffective
strategy.26and54Recently,astudyconcludedthatuncomplicatedhypertensionbyitself
wasnotanindicationforscreeningbutrecommendedscreeningforAAAinelderlywhite
patientswithclaudication.27
TheintroductionoftheOxfordScreeningProgrammenationally(intheUnitedKingdom)
adecadeagowasestimatedtopreventpotentiallysome6000unnecessarydeaths.28A
studyinGloucestershire(UnitedKingdom)demonstratedasignificantreductionin
numberofdeathsfromallaorticaneurysmrelatedcausesinthescreenedportionofthe
malepopulation.57Inonestudy,45malepatientsaged55yearsorolder,withawaist
measurementgreaterthan101cmandnoabdominalaorticaneurysmdetectedon
clinicalexamination,werereferredtoatertiaryreferralcenter.Inaddition,thesepatients
hadatleastoneofthefollowingconditions:hypertension,coronaryarterydisease,
cerebrovasculardisease,andperipheralvasculardisease.Subsequentultrasonography
(ultrasound)revealed6aneurysms,givingadetectionrateof13%.44Existingevidence
seemstofavorscreeningatleastformenaged65to7554or60to80,58butthecostsand
benefitsofmoregeneralscreeninghavenotbeencalculated.54
Thefindingsofarecentstudyindicatethatasecondscreening,approximately4years
aftertheinitialexamination,isoflittlepracticalvalue,mainlybecausetheAAAsdetected
aresmall.Screeningafter8yearsmayprovidetotalyieldssimilartothoseseenininitial
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screening.Further,thisstudyfoundthatrescreeningonlythosesubjectswithan
infrarenalaorticdiameterof2.5cmorgreateroninitialexaminationwouldhavemissed
morethantwothirdsofnewAAAs.59
Management
Surgicalresectionofabdominalaorticaneurysmwasfirstdescribedin1952.Discussion
ofthevariousrepairoptionsisoutsidethescopeofthisreportinterestedreadersare
referredtoothersources,includingtheeditorialbyErnst.60Appropriatemanagementof
patientswithclinicallysuspectedordiagnosedAAAbyprimarycontacthealth
practitionersisreferralforimagingstudiesand/orsurgicalopinion.Surgeryisindicatedin
casesofbothsmallandlargeAAAs25,31and52(Fig10andFig11).Asdiscussedabove,
patientswithsmallaneurysmsrunariskofrupture,whichmaybeashighas9.5%.With
largeAAAs,theriskofruptureisbetween60%and80%.44Theoperativemortalityfrom
electivesurgeryhasprogressivelyfallentolessthan3%.Thus,theriskofdeathwithout
surgery,evenwithsmallaneurysms,issignificant.Naturally,othersignificantmedical
problemsneedtobeconsideredinmakingthedecisiontooperate.44Theauthorsofa
retrospectivestudyof1000consecutiveelectiveAAArepairsconcludedthatpulmonary
andrenaldiseasedidnot,andshouldnot,poseasignificantriskforelectiveinfrarenal
AAAreplacement,althoughcardiacdysfunctionandcoronaryarterydiseaseincreased
morbidityandmortality.61Thelongtermsurvivalofapatientundergoingsurgical
resectionandrepairofanAAAwithanartificialgraftwhosurvivestheimmediate
postoperativeperiodiscomparabletothatinpersonswhoneverhadanAAA.58Collin
emphaticallystatesthatanydoctorwho..doesnotrefertheproblemtoavascular
surgeonshouldbeawarethathemaywillfullybecondemninghis(sic)patienttoatotally
preventableprematuredeath.25and67
Fig10.
OperativeviewofAAAandbifurcationintotheiliacarteries(bottomoffigure)seenthroughalongmidline
incision.(CourtesyofSulzerVascutek,Australia.)
Figureoptions
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Fig11.
OperativeviewofAAAgraftreplacement.AAAgraftreplacementsecuredinplacetheoriginalaneurysm
sacisnowsuturedoverthefrontofthegraftinordertopreventaortoentericfistula.(CourtesyofSulzer
Vascutek,Australia.)
Figureoptions
Chiropractorsare,bytrainingandlegislation,primarycontacthealthcarepractitioners.
Inherentinsuchstatusistheresponsibilitytoconsiderconditionsotherthanmechanical
backpaininpatientspresentingwithspinalpainandputativespinaldysfunctionin
patientspresentingforsocalledchiropracticmaintenancecare62orwellnesscare.
Approximately80%ofpatientspresentingforchiropracticcaredosofor
neuromusculoskeletalpain,withlowbackpainbeingthepredominantpresenting
complaint.3and4Withtheagingpopulation44notedinwesterncountriesandwithcertain
groupsofolderpatients,whountilrecentlymayhavebeendeniedaccesstochiropractic
care,nowgainingaccess(forexample,Australianarmedservicesveteransthrough
recognitionofchiropracticservicesbytheDepartmentofVeteransAffairs),chiropractors
needtobecognizantofAAAandvigilantinassessingtheirolderpatientsforthe
possibilityinteraliaofAAA.Thisinvolvesnotonlycircumstanceswhereanabdominal
aorticaneurysmisthecauseofthepresentingbackpain63butalsocasefindinginvolving
theconsiderationofunrelated,intercurrentillnesses(eg,AAA)inpresentingpatients9
duetothepresenceofknownriskfactors.
ShouldapatientwithriskfactorsassociatedwithAAApresenttoachiropractor,referral
forimaging(usuallyultrasound)withsubsequentvascularsurgicalopinion,where
appropriate,isrequired.64and65InAustralia,referralisusuallyviathepatientsgeneral
medicalpractitioner.Shouldananeurysmpresentfortuitouslyonradiographic
examination,suchreferralisalsomandatory.Patientsknowntohaveanabdominal
aorticaneurysmshouldbewarnedoftheimportanceofcharacteristicsymptomsof
ruptureandthenecessityforimmediateattentionshouldtheyarise.12
ItisnotknownwhetheranAAAisadefinitecontraindicationtochiropracticmanipulation
perse,althoughlargeAAAsareconsideredso.66Further,itisnotknowniftheforces
utilizedinspinalmanipulationareofsufficientmagnitudetocauseruptureofanAAAorif
patientpositioningrequiredforlowbackspinalmanipulation/adjustment66issuchthat
theriskofruptureofanAAAisincreasedbysuchpositioning.Referralshouldbemade
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forfurtherassessmentbecauseoftheriskofspontaneousruptureandthehighmortality
associatedwithrupture.Considerationshouldalsobegiventotherelativelylowsurgical
mortalityrateshouldsurgerybeindicatedandthepossibilitythattheAAAisthecauseof
lowbackpainwhenthisisthepresentingcomplaint.Delayinreferringanatriskpatientin
ordertoofferatrialoftherapymaybeindefensiblemorally,clinically,andina
medicolegalcontext.
Conclusion
AAAshouldbeconsideredinthedifferentialdiagnosisofolderpatientspresentingwith
lowbackpain.Thepossibilityofabdominalaorticaneurysmshouldalsobeconsideredin
asymptomatic,atriskpatients.PatientsatriskforAAAincludemalepatientsoverthe
ageof65years,withahistoryofsmoking,hypertension,chronicobstructiveairway
disease,claudication,andafirstdegreerelativewithanAAA.Electivesurgeryoffersa
curewithlowoperativemortality.Chiropractors,asprimarycontactpractitioners,havea
responsibilitytoreferpatientssuspectedofhavingAAAforappropriateimagingand,
whereindicated,foravascularsurgicalopinion.
Acknowledgements
Theauthorswouldliketothankandacknowledgetheassistanceofthefollowing:Dr
DennisMiddendorp,DC(RMIT,Melbourne,Australia)forassistancewithclinicaldetails
DrAntonyM.Hatton,BAppScChiropractic,MSc,kindlyreviewedthesectionon
pathologyandpathogenesisRoyWebb,MSc,AlexZabobonin,MD,andPeter
Cauwenbergs,DC,PhD(CMCC,Toronto,Canada)forpreparationandanatomic
orientationofthecadavericspecimen(Fig1andFig2)andRenataLumsden,BSc,
MRT(R)andLyndaTanner,MRT(R)(CMCCRadiologyDepartment,Toronto,Canada)
whoradiographedthespecimen(Fig6).ThanksalsotoLizHolden,RN,ofSulzer
Vascutek(Australia)whokindlyprovidedandgrantedpermissiontoreproducethe
originalslidesofFig7,Fig10andFig11.ThepermissionoftheEditorsoftheBritish
JournalofSurgerytoreproducethediagraminFigure3andthepermissionoftheEditors
ofRadiologyandtheAuthorstoreproducethediagnosticimaginginFigure9are
appreciated.BryanGroulxandMichaelCraven(MediaServices,CMCC,Toronto,
Canada)providedassistancewithreproductionofthefiguresforpublication.The
DivisionofGraduateStudies&ResearchatCMCCprovidedfinancialassistance.
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