Abdominal Aortic Aneurysm Clinical Guideline
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1 Abdominal Aortic Aneurysm Clinical Guideline Definition: An abdominal aortic aneurysm (AAA) is an enlargement of the lower part of the aorta that extends through the abdominal area (at times, the upper portion of the aorta in the chest can be enlarged). The aorta is the main blood vessel that carries blood from the heart to the rest of the body. Like most arteries, the aorta is elastic, which allows it to be filled with blood under high pressure. An aneurysm develops when the wall of the artery becomes weakened and distended like a balloon. AAA suspected; are symptoms present? Based on history and physical Asymptomatic AAA Based on incidental imaging (spine MRI, US, CT, x-rays) Evaluate for key symptoms: back, flank, abdominal, leg, groin, scrotal pain signs of aortic fistula flank ecchymosis Evaluate for alternative symptoms: syncope, focal neurologic deficit (especially lower extremities), weakness, dizziness, GI bleed with anemia, anuria, or signs of limb ischemia Abdominal US imaging of choice Risk factor assessment (see Table One) Manage according to risk of rupture (see Table Three) imaging adequate at defining extent of aneurysm and maximum diameter including iliac arteries? Pre-notify vascular surgeon Order abdominal and pelvic CT angiogram Order abdominal and pelvic CT angiogram the patient hemodynamically unstable (SBP less than 100)? Manage according to risk of rupture (see Table Three) Physical exam suggests aneurysm and/or focused bedside ultrasound suggests aneurysm aneurysm known? AAA present? Prepare and transfer to endovascular suite Consider alternative diagnosis December 2015
2 Incidence, Mortality, and Risk Factors Abdominal aortic aneurysms (AAA) continue to be a significant medical and surgical problem with a high associated mortality rate. AAAs affect 4% to 9% of individuals over the age of 60, with a predilection for men between 65 and 79 years of age. The incidence of AAA is increasing as the population ages, with approximately 15,000 people dying from AAA each year in the United States (8,700 of these deaths occur from acute rupture). Abdominal aortic aneurysm is the tenth leading cause of death of older men in the United States and is responsible for 0.8% of all deaths. The mortality rate associated with elective operative repair is 2% to 6%, and there is a significant risk of major complications; higher complication rates are associated with emergent repair. The dreaded complication of an AAA is aortic rupture, which has a death rate of 80% for all patients reaching the hospital alive. The mortality rate is 50% for those patients able to undergo the emergent surgery necessary for vessel repair. An arterial aneurysm is defined as a permanent localized enlargement of an artery to more than 1.5 times its expected diameter. The normal abdominal aorta is 2 cm or less in diameter, and thus an abdominal aortic aneurysm is present once the aorta dilates to a diameter of 3 cm or more. Hypertension, diabetes, and hyperlipidemia contribute to atherosclerosis, which has traditionally been taught as the most significant risk factor for developing an AAA. Recent studies, however, have shown that genetics are more indicative of risk. Ruptured abdominal aortic aneurysms are a highly lethal vascular emergency. Mortality from an out-of-hospital rupture is over 60%, while patients who survive to hospital arrival have an operative mortality rate of approximately 41-50%. In contrast, patients undergoing elective repair have mortality rates of only 5-10% (see Table Two below). Current smokers are 7.6 times more likely to have an AAA than nonsmokers. The prevalence of AAAs among first-degree relatives of patients with an AAA is 15-29%, compared to 2% among relatives of controls. In general, the larger the aneurysm, the greater the risk of rupture. Additional risk factors for rupture include hypertension, underlying chronic obstructive pulmonary disease (COPD), a diameter exceeding 6 cm in men and 5 cm in women, local outpouchings, termed blebs or blisters of the aneurysm wall, eccentric or saccular aneurysms, rapid AAA expansion >1 cm per year, a familial history of AAAs in other first-degree relatives, and an increase in diameter over 5 mm in any 6-month period (regardless of initial or baseline size). Retroperitoneal AAA rupture is more likely to be seen in patients arriving at hospitals alive, while intraperitoneal rupture is usually rapidly fatal. A review of the patient s medical history for risk factors for AAA should include identification of those who have undergone previous surgical AAA grafting or endoluminal stent-graft repair. These patients are at particularly high risk for AAA rupture and face long-term complications, including graft infection, thrombosis, anastomotic aneurysm, dissection, and development of aortoenteric fistulas. Patients with a history of surgical or endovascular repair suffering complications will usually present in similar fashion with complaints of pain and fever. Table One: Risk Factors for AAA Risk Factors For Abdominal Aortic Aneurysm Hypertension Smoking Atherosclerotic disease Turner, Marfan, or Ehlers-Danlos Type IV Syndromes Familial connective tissue defects Male gender Age greater than 50 years Inflammatory or infectious aortitis Known aortic pathology or previous aortic surgery Table Two: Risk Factors for Aneurysm Rupture Hypertension Risk Factors for AAA Rupture Underlying chronic obstructive pulmonary disease (COPD) Diameter greater than 6 cm in men and greater than 5 cm in women Local outpouchings ( blebs or blisters ) of the aneurysm wall Eccentric or saccular aneurysms AAA expansion greater than 1 cm per year Familial history of AAAs in other first-degree relatives Increase in diameter of over 5 mm in any 6-month period Abdominal Aortic Aneurysm - 2
3 Diagnostic Imaging Patients with suspected AAA generally require immediate imaging. CT scanning without contrast, recommended by some as the first diagnostic test in the evaluation of a potentially ruptured AAA, may be used as a confirmatory test after ultrasound (US) has been performed, either in the ED or by radiology when the patient is stable. In unstable patients, focused ED bedside US permits continued resuscitative efforts, without the need to transport patients out of the ED. Ultrasound findings consistent with an AAA include an enlarged abdominal aorta greater than 3 cm (i.e., a 50% increase in its normal diameter) or focal dilatation of the aorta. When there are no contraindications, contrast-enhanced CT scanning is useful in identifying the entire aorta, the retroperitoneum, and the branch and end arteries, which allows for surgical planning. US is insensitive for retroperitoneal bleeding from rupture, and its sensitivity in detecting extraluminal blood flow is as low as 4% in some studies. AAAs typically rupture into the retroperitoneum and are best diagnosed with a CT scan. MRI has high accuracy and provides excellent anatomical detail, but MRI availability and the stability of patients often preclude its use. Vascular Surgery Considerations For intact AAAs, aneurysms greater than 5.5 cm in diameter warrant surgery. Those less than 4 cm are followed with regular imaging. The AAAs that are between 4 cm and 5.5 cm in diameter are in an ambiguous zone for surgical intervention and thus need urgent evaluation by a vascular surgeon. Many institutions use a cut-off of 5 cm for vascular surgery evaluation. Elective surgery is recommended due to the risk of rupture if the AAA is greater than cm in men or greater than 5.0 cm in women, or if diameters between 4.5 and 5.9 cm increase greater than 1 cm/year, or for any increase in diameter over 5 mm in any 6-month period (regardless of initial or baseline size). A recommendation for early elective repair may also be made in patients with a familial history of AAA, local outpouchings of the aneurysm, or eccentric or saccular aneurysms. Abdominal Aortic Aneurysm Management Symptomatic AAA Management: The most critical management step is notifying the surgical and anesthesia team, especially if the patient is hemodynamically unstable. Large bore IV access (x2) should be established and blood sent for cross match. Attempts to resuscitate a hypotensive patient with fully normalized vital signs in the ED should be avoided and patient should be taken to the operating room or endovascular suite immediately if leaking or ruptured aneurysm is suspected with minimal diagnostic testing. Preoperative hypotension is a strong predictor of mortality in patients with a ruptured AAA; correction of hypotension before the aorta is clamped may not improve mortality and may even be harmful. Hypotension may slow the bleeding in patients with AAA and allow local clot formation and tamponade of the rupture site. Raising intravascular volume and blood pressure before occluding the aorta may dislodge clots and cause further bleeding. Large volumes of crystalloid solution may contribute to further bleeding by causing a delusional coagulopathy. Blood pressure should be raised with crystalloid or blood products to a level that maintains adequate cerebral and myocardial perfusion with a reasonable target of a systolic blood pressure of 90 to 100 mmhg. Patients with a leaking or ruptured AAA rarely present with hypertension induced by pain or associated with chronic hypertension; no evidence exists that lowering the blood pressure is beneficial; lowering the blood pressure puts the patient at risk for developing precipitous hypotension. Asymptomatic AAA Management: In asymptomatic patients, the surgical risk of complications from endovascular or open AAA repair is greater than the risk of rupture until the aneurysmal diameter exceeds 5.5 cm. Aneurysms of 5.5 cm or greater are associated with a high risk of rupture and therefore surgical intervention is generally recommended. The 2009 guidelines from the Society for Vascular Surgery recommend observation for asymptomatic AAA less than 5.5 cm in diameter. Other factors may influence the timing of AAA repair which includes coexistent peripheral artery disease, advanced age, ongoing smoking, rapid aneurysm expansion rate, or additional peripheral artery aneurysms such as iliac or femoral aneurysms. A small (<4.0 cm) or medium (4 to 5.5 cm) AAA that expands 0.5 cm over six months at follow-up is considered to be at high risk for rupture. A small to medium-sized AAA (less than 5.5 cm) expands at an average rate of 2-3 mm/year, while larger aneurysms expand at approximately 3-4 mm per year. Aneurysm expansion tends to be more rapid for smokers and it has been estimated that smoking increases the aneurysm expansion rate percent per year. Comparatively, expansion occurs less rapidly in patients with diabetes mellitus or peripheral artery disease. (continues next page) Abdominal Aortic Aneurysm - 3
4 Approaches to Limit Aortic Expansion Smoking cessation is the most important modifiable risk factor in patients with AAA. Moderate physical activity such as running, biking, swimming, hiking, or golfing do not precipitate AAA rupture. Heavy lifting and weight lifting associated with breath-holding or other strenuous activities leading to Valsalva transiently induce significant increases in blood pressure and should be avoided. Beta blockers have NOT been clearly shown to reduce aneurysmal expansion rates. ARBs and ACE inhibitors have NOT clearly demonstrated decreased aneurysm rates. Diuretics and calcium channel blockers have NO impact on expansion rates. Patients with AAA are considered to have a coronary equivalent and should be treated with statins and aspirin daily. Follow-up and surveillance: A statement from the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery estimated the annual rupture risk according to AAA diameter as follows: Zero for AAA <4.0 cm in diameter 0.5 to 5 percent for AAA 4.0 to 4.9 cm in diameter 3 to 15 percent for AAA 5.0 to 5.9 cm in diameter 10 to 20 percent for AAA 6.0 to 6.9 cm in diameter 20 to 40 percent for AAA 7.0 to 7.9 cm in diameter 30 to 50 percent for AAA 8.0 cm in diameter If aneurysm surveillance interval is extended beyond a year, there is potential for patients to be "lost to follow-up." Such gaps in surveillance are associated with AAA rupture; a reminder system should be in place. Patient anxiety associated with a diagnosis of AAA will be reduced with regular surveillance and proper education (see Table Three below). Table Three: Screening Recommendations for Asymptomatic AAA Diameter (cm) Screening Frequency (months) Abdominal Aortic Aneurysm - 4
5 Table Four: ICD-10 - Abdominal Aortic Aneurysm (AAA) ICD 10 I71.00* Description Dissection of aorta, unspecified site I71.01 Dissection of aorta, thoracic I71.02 Dissection of aorta, abdominal I71.03 Dissection of aorta, thoracoabdominal I71.1 Thoracic aneurysm, ruptured I71.2 Thoracic aneurysm without mention of rupture I71.3 Abdominal aneurysm, ruptured I71.4 Abdominal aneurysm without mention of rupture I71.8 Aortic aneurysm of unspecified site, ruptured I71.5 Thoracoabdominal aneurysm, ruptured I71.6 Thoracoabdominal aneurysm, without mention of rupture I71.9 Aortic aneurysm of unspecified site without mention of rupture *Codes with greater degree of specificity should be considered first. References 1. Brewster DC, Cronenwett JL, Hallett JW Jr, et al. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. J Vasc Surg 2003; 37: Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2. 3. Chaikof EL, Brewster DC, Dalman RL, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg 2009; 50: Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;(2):CD Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;(2):CD Fillinger MF, Raghavan ML, Marra SP, et al. In vivo analysis of mechanical wall stress and abdominal aortic aneurysm rupture risk. J Vasc Surg. 2002;36(3): Malkawi AH, Hinchliffe RJ, Xu Y, et al. Patientspecific biomechanical profiling in abdominal aortic aneurysm development and rupture. J Vasc Surg. 2010;52(2): Santilli SM, Littooy FN, Cambria RA, et al. Expansion rates and outcomes for the 3.0-cm to the 3.9-cm infrarenal abdominal aortic aneurysm. J Vasc Surg 2002; 35: Stanley, J. Open surgical treatment of pararenal abdominal aortic aneurysms. In: Aortic Aneurysms, Contemporary Cardiology, Upchurch, G, Criado, E. (Eds), Humana Press, p Truijers M, Pol JA, Schultzekool LJ, et al. Wall stress analysis in small asymptomatic, symptomatic, and ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2007;33(4): Tsai TT, Nienaber CA, Eagle KA: Acute Aortic Syndromes. Circulation 112: 3802, Wittels K. Aortic emergencies. Emerg Med Clin rth Am. 2011;29(4): , vii This clinical guideline outlines the recommendations of Mount Carmel Health Partners for this medical condition and is based upon the referenced best practices. It is not intended to serve as a substitute for professional medical judgment in the diagnosis and treatment of a particular patient. Decisions regarding care are subject to individual consideration and should be made by the patient and treating physician in concert. Original sue Date: December 2015 Abdominal Aortic Aneurysm - 5 Revision Dates:
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