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Chapter 3

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ABDOMINAL AORTIC ANEURYSM (AAA)

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ABDOMINAL AORTIC ANEURYSM (AAA)
  • Risk factors of developing AAA:

    • Age >60 y. About 1 person in 1000 develops an abdominal aortic aneurysm between the ages of 60 and 65. Screening studies have shown that abdominal aortic aneurysms occur in 2% to 13% of men and 6% of women >65 y.

    • Smoking markedly increases risk for AAA. The risk is directly related to number of years smoking and decreases in the years following smoking cessation.

    • Men develop AAA 4 to 5 times more often than women.

    • AAA is more common in white population compared to other ethnicities.

    • History of CHD, PAD, HTN, hypercholesterolemia.

    • Family history of AAA increases the risk of developing the condition and accentuates the risks associated with age and gender. The risk of developing an aneurysm among brothers of a person with a known aneurysm who are >60 y of age is as high as 18%.

  • Risk of expansion:

    • Age >70 y, cardiac or renal transplant, previous stroke, severe cardiac disease, tobacco use.

  • Risk of AAA rupture:

    The evidence suggests that aneurysms expand at an average rate of 0.3 to 0.4 cm y.

    The annual risk of rupture based upon aneurysm size is estimated as follows:

    • <4.0 cm in diameter = <0.5%

    • Between 4.0 and 4.9 cm in diameter = 0.5%–5%

    • Between 5.0 and 5.9 cm in diameter = 3%–15%

    • Between 6.0 and 6.9 cm in diameter = 10%–20%

    • Between 7.0 and 7.9 cm in diameter = 20%–40%

    • ≥8.0 cm in diameter = 30%–50%

    • Aneurysms that expand rapidly (>0.5 cm over 6 mo) are at high risk of rupture.

      Growth tends to be more rapid in smokers and less rapid in patients with peripheral artery disease or diabetes mellitus.

      The risk of rupture of large aneurysms (≥5.0 cm) is significantly greater in women (18%) than in men (12%).

      Other risk factors for rupture: cardiac or renal transplant, decreased forced expiratory volume in 1 second, higher mean BP, larger initial AAA diameter, current tobacco use—length of time smoking is more significant than amount smoked.

  • ACCF/AHA 2005/2011 recommendations:

    Pharmacologic therapy:

    • All patients with AAA should have BP and fasting serum lipids monitored and controlled as recommended for patients with atherosclerotic disease (Class I, LOE C).

    • Smoking cessation: counseling and medications should be provided to all patients with AAA or family history of AAA.

    • Patients with infrarenal or juxtarenal AAA 4.0 to 5.4 cm in diameter should be monitored by ultrasounds or CT scans every 6 to 12 mo to detect expansion (Class I, LOE A).

    • In patients with AAA <4.0 cm in diameter, monitoring by ultrasound every 2 to 3 y is reasonable (Class IIa, LOE B).

    • Perioperative administration of β-adrenergic blocking agents, in the absence of contraindications, is indicated to reduce the risk of adverse cardiac events and mortality in patients with coronary artery disease undergoing surgical repair of atherosclerotic aortic aneurysms (Class I, LOE A).

    • β-adrenergic blocking agents may be considered to reduce the rate of aneurysm expansion in patients with aortic aneurysms (Class IIb, LOE B).

  • Surgical therapy:

    • Patients ...

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