Overview Snapshot A 61-year-old male with a history of CAD and HTN is found to have a pulsatile abdominal mass on palpation. A bruit is heard on ausculation. Introduction Characterized by ballooning (aneurysmal) dilatation of the aorta Occurs most commonly secondary to atherosclerosis most are abdominal in origin 90% occur below the renal arteries rarely present at or around the aortic arch Risk factors include HTN hypercholesterolemia atherosclerosis family history tobacco male gender increasing age Marfan's syndrome Presentation Symptoms usually asymptomatic discovered incidentally on exam or imaging study can present with pulsatile sensation back pain vague epigastric pain ruptured aneurysms present with hypotension severe, tearing abdominal pain radiating to the back Physical exam a pulsatile mass in the abdomin abdominal bruits evidence of lower extremity arterial insufficiency Imaging Ultrasound all men age 65+ who have ever smoked should be screened with an ultrasound is diagnostic gold standard < 5 cm => monitor with repeat ultrasounds > 5 cm => surgical repair and further management used to follow AAA over time AXR/KUB may show vascular calcification CT best modality to determine anatomy and size Aortogram for definitive diagnosis Differential Pancreatitis, pseudocyst, appendicitis, gallbladder disease, aortic dissection Treatment Nonoperative clinical observation indications asymptomatic and < 5 cm in size < 6 cm in poor surgical candidate Operative surgical repair indications large lesions > 5.5 cm in the abdomen > 6 cm in the thoracic cavity smaller lesions that are rapidly enlarging on follow-up emergent surgery indications symptomatic lesions ruptured aneurysms Complications Myocardial infarct is the most common cause of death after elective surgical repair Thrombosis and post-operative emboli can lead to renal failure GI hemorrhage from colonic ischemia Aortoduodenal fistula can occur s/p surgery and graft placement presents with GI bleed Other complications endograft infection, ischemia of internal organs (including kidney, intestines, and pelvic organs) contrast-induced nephropathy or allergic reaction aortocaval fistula (though rare) gross hematuria 2/2 congestion of weak bladder veins leading to rupture Prognosis & Prevention Prognosis ranges depending on severity of lesion and timing of diagnosis good to excellent in smaller lesions and when identified early poor if aneurysm leads to dissection and/or rupture Prevention possible if identified early via thorough physical exam and regular primary care visits screening with ultrasound indicated in men ages 65-75 who have ever smoked