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Key Features

Essentials of Diagnosis

  • Most aortic aneurysms are asymptomatic until rupture, which is catastrophic

  • Aneurysms measuring 5 cm are palpable in 80% of patients

  • Back or abdominal pain with aneurysmal tenderness may precede rupture

  • Hypotension

  • Excruciating abdominal pain that radiates to the back

General Considerations

  • The aorta of a healthy young man measures approximately 2 cm

  • An aneurysm is considered present when the aortic diameter exceeds 3 cm

  • Aneurysms rarely cause rupture until diameter exceeds 5 cm

  • 90% of abdominal atherosclerotic aneurysms originate below the renal arteries

  • Aortic bifurcation is usually involved

  • Common iliac arteries are often involved

Demographics

  • Found in 2% of men over age 55

  • Male to female ratio is 4:1

Clinical Findings

Symptoms and Signs

  • Most asymptomatic aneurysms are discovered on ultrasound or CT imaging as part of a screening program or during the evaluation of unrelated abdominal symptoms

  • Symptomatic aneurysms

    • Mild to severe midabdominal pain due to aneurysmal expansion often radiates to lower back

    • Pain may be constant or intermittent, exacerbated by even gentle pressure on aneurysm sack, and may also accompany inflammatory aneurysms

  • Inflammatory aneurysms have an inflammatory peel, similar to the inflammation seen with retroperitoneal fibrosis, surrounds the aneurysm and encases adjacent retroperitoneal structures, such as the duodenum and, occasionally, the ureters

  • Ruptured aneurysms

    • Severe pain

    • Palpable abdominal mass

    • Hypotension

    • Free rupture into the peritoneal cavity is lethal

    • Most aneurysms have a thick layer of thrombus lining the aneurysmal sac

    • Embolization to lower extremities is rarely seen

Differential Diagnosis

  • Perforated viscus, eg, peptic ulcer, appendix, gallbladder, diverticulitis

  • Pancreatitis or pancreatic pseudocyst

  • Urinary calculi

  • Pyelonephritis

  • Gastritis

  • Intestinal ischemia

  • Bowel obstruction

  • Musculoskeletal pain

  • Sudden death due to other causes, eg, ventricular fibrillation, myocardial infarction, pulmonary embolism

Diagnosis

Laboratory Tests

  • Hematocrit will be normal, since there has been no opportunity for hemodilution

  • Patients with aneurysms may also have the cardiopulmonary diseases of elderly male smokers, which include

    • Coronary artery disease

    • Carotid disease

    • Kidney impairment

    • Emphysema

  • Preoperative testing may indicate the presence of these comorbid conditions

Imaging Studies

  • Abdominal ultrasonography

    • Diagnostic study of choice for initial screening

    • Useful in screening 65- to 75-year-old men, but not women, who have a history of smoking

    • Repeated screening does not appear to be needed

  • Abdominal or back radiographs: curvilinear calcifications outlining portions of aneurysm wall may be seen in approximately 75% of patients

  • CT scans

    • Provide a more reliable assessment of aneurysm diameter

    • Should be done when the aneurysm nears the diameter threshold (5.5 cm) for treatment

  • Contrast-enhanced CT scans

    • Show the arteries above and below the aneurysm

    • Visualization of this vasculature is essential for planning repair

Treatment

Emergency Repair
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