VASCULAR II A 65 year old man presents because of some abdominal discomfort.

On closer questioning, he states that he feels as if his heart is beating in his abdomen. 1. What condition could he be suffering from? AAA 2. What other clinical features could he possibly be experiencing from this condition? 30% are asymptomatic AAA are incidental findings 20% are symptomatic PAIN in the central abdomen (caused by stretching of the aa.), loin (caused by local pressure on the nerve), groin, iliac fossa, back (caused by erosion of the lumbar vertebrae) DULL ACHING PAIN. ACUT E SEVERE pain ruptured AAA hypotensive shock death Pulsatile Mass Intermittent Claudication, Rest Pain, Critical Limb Ischemia thrombosis of AAA, or break off of emboli from thrombus in AAA which causes obstruction of blood flow to the LL. Swollen, BLUE, painful limb due to obstruction of the adjacent vein by the dilated arteries. Ruptured AAA into adjacent vein result in acute arterio-venous fistula elevated neck vein 3. What other clinical features should be sought. > Feel for expansile pulsation. 4. What investigations are required and why. > Plain Lateral view and AP view of abdominal X-ray. > USS the best for monitoring the size, diagnostic, > CT & arteriography for pre-op investigation. Not for surveillance because contain ionizing radiation. Determine ACCURATELY the size & extent of aneurysm, visceral arteries + surrounding structures or other abdominal pathology ie. Liver mets. If CT scan shows AAA extends above the renal aa, then thoraco-abdominal op approach is required which carries higher risk. 5. What are the options in the management of this gentleman? If the aneurysm is < 5.5cm, do not operate. Because rish of open surgery is greater than risk of rupture. Monitor the patient 3-6mthly by USS. USS only accurate to about 0.5cm hence, CT scan will be arranged if aneurysm reaches 5.0cm. Assess Fitness for surgery. If more than 0.5cm increase per year, refer immediately. All symptomatic AAA should be considered for surgical repair eg. Abdominal pain, IC, rest pain. Pain predates rupture. Limb loss is common if left untreated.

 OPEN AAA repair place a prosthetic graft in the aneurismal segment. Endovascular stent-graft repair of AAA. place a covered stent into the AAA through femoral arteriotomy or percutaneously. faster recovery, reduced number of hospital stays, reduction in mortality and morbidity, improved post-operative life. Cons: high secondary intervention rate, expensive, <50% of AAA are suitable for this. Post-op 4 yrs, no advantage in health-related QOL.

A 65 year old man presents because of left sided loin pain which is felt also in the abdomen. 1. 2. What could he be suffering from. What are the important clinical features which should be sought.

Examination showed that he was obese and there was some tenderness on abdominal examination 3. What investigations are required. A plain abdominal film is shown. Describe the abnormality seen on the film. 4. What further investigations are required. 5. Outline the management options available.

1. Symptomatic AAA 2. Fainting, Dizziness, cold clammy pale skin, rapid shallow breathing, N+V, sudden SEVERE abdominal or back pain with or without radiation. 3. Plain Abdominal X-ray AP and Lateral view, Shows huge abdominal aneurysms FBC, U&E&C, ESR/CRP 4. USS, CT-scan 5. As above.