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Inflammatory Abdominal Aortic Aneurysm with Obstructive Nephropathy in a 71 yr old Male

Inflammatory Abdominal Aortic Aneurysm with Obstructive Nephropathy in a 71 yr old Male. By Chijioke Chinaka. HS, 71 yr Old Male Background Hypertension Asthma T/F a peripheral Hospital Incidental finding of 10cm Non leaking AAA On treatment for PE Presentation Left upper leg pain

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Inflammatory Abdominal Aortic Aneurysm with Obstructive Nephropathy in a 71 yr old Male

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  1. Inflammatory Abdominal Aortic Aneurysm with Obstructive Nephropathy in a 71 yr old Male By ChijiokeChinaka

  2. HS, 71 yr Old Male • Background • Hypertension • Asthma • T/F a peripheral Hospital • Incidental finding of 10cm Non leaking AAA • On treatment for PE • Presentation • Left upper leg pain • Swelling • Cellulitis on the foot • Abdominal pain0, back pain0, urinary symptoms0 • Examination/investigations • Swollen tender upper left leg; Duplex scan • LIF mass; CT

  3. CT SCAN Inflammatory Aneurysm Hydronephrosis Over Distended Bladder Bilateral thromboilio-femoral veinous system

  4. Hydronephosis Over distended blader

  5. Thrombosed ilio femoral venous system

  6. Sagittal section

  7. Examination • Pulse 90b/min • BP 120/80 mmHg • Left Lower limb • Mildly swollen • Groin tenderness • Cellulitic dorsum of foot • Abdomen • Soft • Non tender pulsatile mass • Investigation • Bloods: Cr – 140 mmol/l, Urea – 4.1 mmol/l, CRP – 71, ESR – 42mm/hr, WCC – 8.78, Hb – 11.6

  8. Impression - Inflammatory Aneurysm • Issues • Non Ruptured massive AAA • Bilateral Hydroureter • Poor Renal Function • Plan • Urology consult • Nephrology consult • Work up for optimization • Urgent surgery

  9. Nephrology • Continue protective measures • N-acetyl cysteine • Fluids • Urology • Hydronephrosis 20 ?Bladder outlet obstruction • USS • PSA

  10. USS • Bladder not trabeculated • Prostate not enlarged • Kidney • Right 9.7cm • Left 9.5cm • Right Hydronephorosis • No evidence of left hydronephrosis • PSA • Total PSA 2ng/ml • Free PSA 0.5ng/ml • Ratio 25%

  11. Cr - 105, Echo – EF 50%, • Surgery (2 options) • Open Repair • Complicated • Difficult access • Fistulation • Endovascular Stenting (EVAR) • Suitability • Minimal access

  12. EVAR(surgery) • 6th Day • Aorto – iliac + Fem - Fem cross over • Post Op • Resolved left hydronephrosis • Persistent right

  13. DISCUSION

  14. Inflammatory Abdominal Aortic Aneurysm

  15. Definition • A distinct sub group of AAA • exuberant inflammatory reaction • marked peri-aneurysmal and retroperitoneal fibrosis • dense adhesions of adjacent abdominal organs • Incidence • 5% to 10% of all AAA • > Male (M:F = 30:1 to 6:1) • Mean Age; 62 to 68 yrs • Smokers 77% to 100% • Aetiology • Unknown >90% • Genetic factor (HLA –DR B1 locus) • + veFHx (17%) • Unlikely infective aetiology : Chlamydia pneumoniae. • ?variant of retroperitoneal fibrosis. Walker et al. Br J Surg 1972;59: 609 -14, T. Tang et al EJVES Vol 29 Issue 4, 2005; SS Nitecki et al J VascSurg23 (1996) (5), pp. 860–868.

  16. Pathophysiology • Inflammation • Inflammatory cell infiltrate • Both in IAAA and non – IAAA but > in the later • Macrophages, T- lymphocytes and B- lymphocytes • Immune Response • Infection • Herpes simplex and Cytomegalovirus • Chlamydia pneumonia • Presentation • Symptoms • Usually symptomatic (80%) • Abdominal pain + back pain • Weight loss • Asymptomatic (20%) A. Stella et al Ann Vasc Surg 7 (1993), pp. 229–238.

  17. Signs • Tender pulsatile abdominal mass (15% to 30%) • Elevated ESR (40% to 88%) • Raised CRP • Auria (Rare) • Others • Ischaemic foot • Intermitent claudication • Diagnosis • CT Scan • Sensitivity 83.3% • Specificity 99.7% • Overall accuracy 93.7% • Ultrasound Scan • MRI • Nuclear Medicine

  18. Inflammatory AAA Atherosclerotic AAA Older patient Usually asymptomatic Unrelated Less thickening of wall Less fibrosis More likely to rupture • Younger patient • Usually symptomatic • Elevated inflammatory maker • Marked thickening of Aneurysmal wall • Fibrosis of Adjacent retroperitoneun • Less likely to rupture • Strongly related to smoking

  19. Treatment • Non Operative • Extensive fibrosis • Steroid therapy • Risk of Rupture • Operative • Open Surgery • High technical difficulty • Increased morbidity/mortality rate • Longer operating time • Longer hospital stay • EVAR • Longer-term peri aneurysmal regression • Uretrolysis/Management of Related Pathology

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