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Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm. Orla Dunlea Neurosurgical Registrar. What is it?. Retro-peritoneal. Infrarenal. >50% over normal artery diameter. Natural history is to enlarge & rupture, unless die from other causes. Inferior Mesenteric artery sacraficed. What causes it?. How does it present?.

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Abdominal Aortic Aneurysm

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  1. Abdominal Aortic Aneurysm • Orla Dunlea • Neurosurgical Registrar

  2. What is it? Retro-peritoneal Infrarenal >50% over normal artery diameter Natural history is to enlarge & rupture, unless die from other causes Inferior Mesenteric artery sacraficed

  3. What causes it?

  4. How does it present?

  5. Lay your hands on me • Most aneurysms are picked up incidentally - either by a clever doctor or scan • Take a minute to palpate your patient’s abdomen, regardless of the reason you are seeing them Even a plain abdominal x-ray (especially lateral) can be a clue with calcification outline

  6. Feel your way • General • Patient laying flat with 1 pillow • Pulsatile swelling in the upper abdomen • Stable/in shock • Pulse - regular/irregular - no delay • ?Carotid bruit

  7. Examination of AAA patient • Abdomen • Inspection - sternotomy scar, abdominal scar • Palpate - ?tender to touch (worry) expansile/pulsatile/diameter/upper limit/side to side • Groin - ?femoral pulses/femoral aneurysms • Auscultate for bruit • Peripheral vascular examination (popliteal aneurysm)

  8. Size Matters • How big is it? • <5cm - follow up • >5cm likely need intervention • If <5cm but increasing in size quickly = intervention Except for women

  9. Investigations • Ultrasound • Screening • Initial diagnosis • Relationship to renal arteries • Not helpful if obese

  10. Investigations • CT • If obese • Planning surgery

  11. Other investigations • CTA/MRA/Angiogram • Bloods including G&S & coag • ECG • CXR • Echo • PFTs

  12. In Theatre • Timeout • GA • Arc line • Catheter • NG • ABs • Fluids • Cell saver

  13. Layers • Skin • Anterior layer of rectus sheath/linea alba • Rectus abdominus muscles • Posterior layer of rectus sheath • Transversalis fascia • Extra-peritoneal fat • Peritoneum • Greater omentum/Stomach/transverse colon • Small intestine & mesentery/pancreas/duodenum

  14. Post operative Immediate Haemodynamics Fluid balance Pulses Later • Pneumonia - 5% • Myocardial infarction - 2-5% • Groin infection - Less than 5% • Graft infection - Less than 1% • Colon ischemia - Less than 1% if elective and 15-20% if ruptured • Renal failure related to preoperative creatinine level, intraoperative cholesterol embolization, and hypotension • Incisional hernia - 10-20% • Bowel obstruction • Amputation from major arterial occlusion • Blue toe syndrome and cholesterol embolization to feet • Impotence in males - Erectile dysfunction and retrograde ejaculation (>30%) • Paresthesias in thighs from femoral exposure (rare) • Lymphocele in groin - Approximately 2% • Late graft enteric fistula • Death - 1.8-5% if elective and 50% if ruptured

  15. EVAR Up to 10% repeat procedure 2000 Co-morbidities

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