ABDOMINAL AORTIC ANEURYSM

ABDOMINAL AORTIC ANEURYSM

1 - 5 % of general population affected Incidence is increasing 100,000 250,000 new cases discovered each year in the U.S. Natural history is to enlarge & rupture unless death occurs from other cause Rupture carries a 90% mortality

DEFINITION:
also known as AAA, pronounced as "triple-a" is a localized dilatation (ballooning) of the abdominal aorta exceeding the normal diameter by more than 50 percent is the most common form of aortic aneurysm Approximately 90 percent of abdominal aortic aneurysms occur infrarenally (below the kidneys), but they can also occur pararenally (at the level of the kidneys) or suprarenally (above the kidneys). Such aneurysms can extend to include one or both of the iliac arteries in the pelvis. occur most commonly in individuals between 65 and 75 years old and are more common among men and smokers.

CAUSES:
Heredity Hypertension Atherosclerosis Smoking/ Tobacco use Infection Trauma Arteritis Cystic Medical Necrosis Male gender Emphysema Obesity

PATHOPHYSIOLOGY
The most striking histopathological changes of aneurysmatic aorta are seen in tunica media and intima. These include accumulation of lipids in foam cells, extracellular free cholesterol crystals,calcification, thrombosis, and ulcerations and ruptures of the layers. There is an adventitial inflammatory infiltrate. However, the degradation of tunica media by means of proteolytic process seems to be the basic pathophysiologic mechanism of the AAA development. Some researchers report increased expression and activity of matrix metalloproteinases in individuals with AAA. This leads to elimination of elastin from the media, rendering the aortic wall more susceptible to the influence of the blood pressure. There is also a reduced amount of vasa vasorum in the abdominal aorta (compared to the thoracic aorta); consequently, the tunica media must rely mostly on diffusion for nutrition which makes it increasingly susceptible to damage. Hemodynamics affect the development of AAA. It has a predilection for the infarerenal aorta. The histological structure and mechanical characteristics of infrarenal aorta differ from those of the thoracic aorta. The diameter decreases from the root to the bifurcation, and the wall of the abdominal aorta also contains a lesser proportion of elastin. The mechanical tension in abdominal aortic wall is therefore higher than in the thoracic aortic wall. The elasticity and distensability also decline with age, which can result in gradual dilatation of the segment. Higher intraluminal pressure in patients with arterial hypertension markedly contributes to the progression of the pathological process. Suitable hemodynamics conditions may be linked to specific Intraluminal Thrombus (ILT) patterns along the aortic lumen, which in turn may affect AAA's development.

CLINICAL MANIFESTATIONS
Pulsating sensation in the abdomen

Deep penetrating pain mainly in the back, When the aneurysm ruptures, the first symptom is excruciating pain in the lower abdomen and back and tenderness in the area over the aneurysm. Bleeding can cause hypovolemic shock with hypotension, tachycardia, cyanosis and altered mental status The bleeding can be retroperitoneal or intraperitoneal or the rupture can create an aortocaval or aortointestinal (between the aorta and intestine) fistula. Flank ecchymosis (appearance of a bruise) is a sign of retroperitoneal hemorrhage and is also called Grey Turners sign.

DIAGNOSIS
A routine physical examination reveals a pulsating mass in the midline of the abdomen. Upon auscultation, a bruit can be heard. Plain abdominal radiographs may show the outline of an aneurysm when its walls are calcified. Ultrasonography is used to screen for aneurysms and to determine the size of any present. Additionally, free peritoneal fluid can be detected. CT scan has a nearly 100% sensitivity for aneurysm and is also useful in preoperative planning, detailing the anatomy and possibility for endovascular repair. In the case of suspected rupture, it can also reliably detect retroperitoneal fluid. Abdominal x-rays detects an aneurysm that has calcium deposits in its wall, but this procedure provides little information.

Sagittal CT image of an AAA.

Biomechanical AAA Rupture risk prediction.

CT image of an AAA 40,8 mm.

An axial contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 by 3.8 cm

A rupture AAA with an open arrow making the aneurysm and the closed arrow the free blood in the abdomen

The faint outline of the calcified wall of a AAA as seen on plain X-ray

Ultrasound image of a normal abdominal aorta measuring 1.9 cm in diameter.

TREATMENT
Antihypertensive drugs (ACE inhibitors, betablockers and statins) for aneurysm that are less than 2 inches Imaging procedures are performed to estimate the rate of enlargement and determine when surgery will be necessary. Surgery which consists of inserting a synthetic graft to repair the aneurysm. Stent grafting

POSSIBLE COMPLICATIONS
When an abdominal aortic aneurysm ruptures, it is a true medical emergency. Aortic dissection occurs when the innermost lining of the artery tears and blood leaks into the wall of the artery. This most commonly occurs in the aorta within the chest. Complications include: Arterial Embolism Heart attack Hypovolemic shock Kidney failure Stroke http://www.medicinenet.com/abdominal_aortic_aneurysm /article.htm

NURSING MANAGEMENT
Fluid Management: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume. Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain Environmental Management: Comfort: Manipulation of the patients surroundings for promotion of optimal comfort

 Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger Calming Technique: Reducing anxiety in patient experiencing acute distress Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptomsof impaired cardiac function Circulatory Care: Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness

PREVENTION
To reduce the risk of developing aneurysms: Eat a heart-healthy diet, exercise, stop smoking (if you smoke), and reduce stress to help lower your chances of having a blocked artery again. Your health care provider may give you medicine to help lower your cholesterol. If you were given medicines for blood pressure or diabetes, take them as your doctor has asked you to. Men over age 65 who have ever smoked should have a screening ultrasound performed once.