AAA

Aneurysm- originated from Greek word aneurusma, meaning to widen

AAA is defined as A permanent localised dilatation of an artery of more than 50% of the
normal diameter of the artery in question by Society of Vascular Surgery.

Abdominal aorta the commonest site of all aneurysms- 90%, infra-renal 95%.

Epidemiology

From ultrasound-screening studies, AAA 3 cm 4-5%; 4 cm 1-3% of population

AAA 4cm in men, 1% over 60 y/o and 10% over 80 y/o.

Male 4-6 X more can than female

Aetiology

Causes are unclear but 90% are thought to be due to degenerative process.

Familial propensity- 30% incidence in siblings of aneurysm patients.

Some studies suggested X-linked and autosomal dominant inheritance.

Other causes:

1) infection (mycotic aneurysms)

2) cystic medial necrosis
3) arteritis
4) trauma
5) disorders of connective tissue

Pathogenesis

Aneurysm is characterised by reduction in medial and adventitial elastin and collagen,

reduction in smooth muscle cells and infiltration of inflammatory cells (lymphocytes and
macrophages)

The process involves proteolytic process by matrix metalloproteinases, inflammation and

biomechanical wall stress.

As aneurysm dilates, the stress on the vessel wall increases (Laplaces Law)
Turbulent blood flow predisposes mural thrombus formation.

Clinical features

75% asymptomatic and discovered incidentally.

Most clinical symptoms are due to rupture or embolic event

Rupture- Triad of abdominal or back pain, hypovolaemic shock, and pulsatile abdominal
mass. Elderly with unexplained hypotension and unexplained abdominal symptoms- must
think of ruptured AAA.

Embolism- acute limb ischeamia.

Other form of presentations:

1) lower back pain, weight loss, raised ESR (inflammatory AAA)

2) symptoms to adjacent structures (dysphagia, ureteric or caval obstruction)
3) rupture to adjacent structures (IVC- CCF with abdominal bruit, renal failure with
peripheral ischeamia, 4th part of duodenum-massive GIT bleed)

Investigations

Ultra-sound- first-line investigation for detection of AAA

CT- first-line investigation during pre-operative assessment- assess morphology and

relation to renal and visceral arteries

Management

Risk of rupture, less than 5.5cm, 1 % annual rupture rate, 5.5 cm 10%, 7 cm- 30%

Mortality of ruptured AAA- 90%

Indication of intervention for non-ruptured AAA:

1) diameter of 5.5cm or more
2) increment of 1 cm or more in 1 year
3) symptomatic

Open surgery- mortality reported 2-10% (elective), around 50% (emergency)

Open vs Endovascular Treatment

EVAR-1 (1000 patients fit for surgery with AAA 5cm)

- 30 day operative mortality for EVAR was one third of open repair (1.7% vs 4.7%)
- EVAR has higher re-intervention rate
- No significant benefit for EVAR on 4 year all-cause mortality
- Sustained 3 % 4-year aneurysm related-mortality, EVAR over open
- Improved quality of life in first 3 months for EVAR

DREAM Study (Dutch Randomised Endovascular Aneurysm Management)

- results mirrored EVAR-1 but not statistically significant.

EVAR-2 (340 considered unfit for surgery, randomised for EVAR or best medical
treatment)
- no difference in year all-cause mortality, aneurysm related-mortality and quality
of life.

Cases suitable for EVAR- Infrarenal neck diameter of less than 3cm, length more than 1
cm and angulation less than 60 degree.

There are emerging evidence for EVAR in ruptured AAA, 6-17% mortality rate.

Complications of open repair

Early Late
-bleeding - graft infection
-co-agulopahty - aorto-enteric fistula
-Acute limb ischeamia (embolic event) - pseudoaneurysm
-right sided colonic ischeamia - sexual dysfunction
-spinal cord ischeamia (rare)
-ARF and MI

Complications of EVAR
a) Endoleak

1 Failure of proximal or distal seal so that blood leaks around the device into the sac
2 Filling of the sac via collateral vessels (inferior mesenteric artery or lumbar arteries)
3 Break in the graft material or dislocation of a modular component of the stent-graft
4 A high degree of porosity of the graft material
5 Endotension or increasing aneurysm size without a visible leak

Early type 2- conservative

b) Occlusion of stent graft

 c) Infection
d) Migration
e) Wound site complications
f) Distal embolisation
g) Post-implantation syndrome- fever, leucocytosis and raised inflammatory markers
(within a few days of procedure, self-limiting)

Follow-up post EVAR

CT scan 3, 6 and 12 months post EVAR, then annual CT and X-ray (for graph mechanical
complications)

Medical optimization before op

- General cardio-respiratory optimization

- Stop smoking
- Statins
- Beta-blockers
(All improved post-op survival)

Future target therapy

- Focused on inhibition of matrix metalloproteinases

- Recent study show inhibition of a novel stress-activated proteinase,
Jun N-terminal kinase prevented the development and causes regression of AAA
in mouse model

The management of those with a diameter between 4-5.5 cm has been addressed in the
recently published UK Small Aneurysm Trial in which 1000 patients were randomised to
operation or surveillance. This showed no survival advantage for those patients offered early
operation