graft site Venous DIC Atelectasis Pneumonia ARDS Pulmonary oedema Pulmonary Embolism Arrhythmias Ischaemia/MI Myocardial Depression

Mesenteric ischaemia Paralytic ileus Malnutrition

Bleeding

definition

dilation of the abdominal aorta (> 3cm) formed by widening of the lumen secondary to weakness of the aortic wall, that may extend proximally or distally along the artery male to female ratio is 8:1 Smoking

Respiratory risk factors

Hyperlipidaemia Hypertension Peripheral vascular disease Marfan Syndrome, Ehlers-Danlos syndrome Prevalence of AAA in siblings of patients with known aneurysm is approximately 4 times greater than in individuals with no family history Degenerative aneurysm Hereditary, atherosclerosis

CCF Cardiac

Gastro-Intestinal Tract UTI Renal failure Renal

complications Pseudo-aneurysm types Mycotic aneurysm

Arterial injury, trauma, angiography, surgery, infection Infection, septic emboli degenerative with possible immunological reaction Hypertension, cystic medial necrosis Incidental finding

Acute limb ischaemia Deep venous thrombosis Infection Dehiscence Incisional hernia

Lower Limbs

Inflammatory aneurysm Dissecting aneurysm

Wound Complications Routine examination Ultrasound Sound scanning/Plain Film Abdomen for other reason Patient notices pulsatile mass

Paraplegia Pseudo-aneurysm formation Aorto enteric fistula

Spinal Cord Infected graft Impotence

Ischemia Reperfusion Syndrome Asymptomatic - 75% Rupture/Leak emergency repair Symptomatic urgent repair Asymptomatic 5.5 cm elective repair to prevent death from rupture Mortality from rupture 75-80%, only 50% reach hospital of which 50% mortality 30 days post-repair Mortality from elective repair 5% 20-25% morbidity Objectives of Surgery:

Rupture Symptomatic - back/flank/abdominal pain, embolisation Rapid increase in size >0.5 cm/year Asymptomatic 5.5 cm exact lower limit controversial Aorto-caval/Aorto-enteric fistula U/S, CT, MR Angiogram 3D reconstruction of images Size/extent of aneurysm abdominal/thoraco-abdominal Relation to renal arteries/involvement of iliac vessels indication

Abdominal Aortic Aneurysm

clinical features

symptoms

preoperative radiological investigations open surgery

Distal Embolisation Symptomatic (blue toe syndrome)

70% will have significant coronary artery disease Cardiac co-morbidity results in 75% of operative mortality FBC, ECG, CXR, Stress test, Echo, Coronary Angiogram Exercise tolerance, CXR, ABGs, PFTs Coagulation screen, LFTs, Urea & Creatinine Ruptured aneurysm 66% of ruptures die before reaching hospital 50% peri-operative & postoperative mortality rate i.e. < 20% survival Hypotension Anuria Low Hb Coagulopathy Pre-op cardiac arrest Indicators of Outcome: assessment Fitness for Surgery: Leak

(abdominal/back /flank pain) (hypovolaemic shock, sudden epigastric/back pain) (aorto-caval/aorto-enteric)

Rupture

Fistulation Rare Emergency Surgery: surgical management

Inspect for abdominal pulsations at eye level

60% of aneurysms are suitable Reduced physiological stress Reduced morbidity Reduced mortality Small incisions No laparotomy No cross clamping Rapid recovery Contrast load - renal toxicity Endo-leak Graft migration Suitable of older age groups Suitable in significant co-morbid illnesses Laparotomy Aortic Cross-Clamping Ischaemia-Reperfusion

Feel for pulsatile/expansile mass in 2 planes Why: Listen for bruits Examine femoral and popliteal arteries Size, site and extension U/S - CT Angiography: Tortuosity Involvement of renal arteries Evidence of leak < 5cm:10% 5-5.9 cm:25% >6 cm:35% >7 cm:75% <4cms:0.2cm/year 4-5cms:0.5cm/year >5cms:0.7cm/year Urgent intervention if rate of expansion exceeding the yearly rate !

Advantages endovascular Disadvantages investigation

5years rupture rate:

Advantages over Surgery: Avoids the major 3 insults of surgery:

Rate of expansion:

Made by Afiq, Faradila, Hazirah, Mardiana and Nurhanis [RCSI 2011]