CLINICAL CASE STUDY

PRESENTATION
aaa?

R.VINOEDH NAIDU @ PRP
2014/2015
PRECEPTOR : ms. leao

Objectives
Review
Epidemiology & histopathology
Signs and symptoms
Appropriate diagnostic & screening tools
Treatment options and benefits

Discuss
Endovascular repair
Future care plan
HISTORY OF PRESENTING ILLNESS:
Sudden onset pain, aggravated by
cough & radiate to back,
Mass > 1 year,
On/off dizziness, vomiting + LOA,
Scan was done in HKN:
*No free fluid
*Vascular mass 6x6cm
Pulsatile mass palpable over the left
side of the abdomen.
CRT <2s in all limbs distally
CHIEF COMPLAINT:
Pain over the left abdominal mass 1/7,
Abdominal swelling.
DIAGNOSIS:
ABDOMINAL AORTIC
ANEURYSM
SOCIAL HISTORY / FAMILY
HISTORY:
Non- smoker, non-alcoholic
No family history of
malignancy
REVIEW OF SYSTEM:
BP : 117 / 72 mmHg
PR : 73 beats/min
T : 37 C
SPO2 : 98%
PATIENT DEMOGRAPHIC:
Name : SHA
Age : 81 years old
Gender : Female
Race : Malay
Weight : 36 kg
DOA : 30 / 06 / 2014
T/O : 03 / 07 / 2014
PAST MEDICATIONS:
Tab. Metoprolol 25mg BD
PAST MEDICAL HISTORY
Hypertension
ADL Independent
RADIOLOGY FINDINGS :
1. US ABD - Dilated abdominal
aorta
2. CTA Non-leaking AAA but
with small hematoma
near aneurysm.
1. CTA Active leaking AAA
COMPLIANCE ISSUE:
Patients is compliant towards her
medication.
ALLERGY:
NKDA
PATHOPHYSIOLOGY
Definition: Pathological dilatation with inflammation
of the normal aortic lumen
3
Variety: Degenerative, Traumatic, Mycotic,
Anostomotic
Gradual reduction in the aortic wall matrix proteins
(elastin).*
Degraded by local overexpression of proteolytic
enzymes (matrix metalloproteinases).*
Prevalence
7.5 % of men older than 65
1.3 % of women older than 65


70-80 %
Asymptomatic !
Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery
EPIDEMIOLOGY
1

New England Journal of Medicine

Symptoms and Signs
Asymptomatic
Inflammatory AAA may cause back pain

Pulsatile abdominal mass
Mid-abdomen just above and left of the umbilicus

Ruptured AAA
2
1. Sudden onset abdominal pain ~ size >4cm
2. Pulsatile mass
3. Hypotension
4. Emphysema *
5. Duodenal obstruction *
6. Blue-toe Syndrome

Chervu A, et. al., 1995.
VITAL SIGNS











NORMAL
RANGE
30/6/14 1/7/14 2/7/14 3/7/14
BP <125/85
122/ 63 172/85
77/52*
138/67
101/63
118/69
120/78
120/78
104/53
128/73
TEMP 38
AFEBRILE
RR 16-20
20 20
13
17
14
11
18
18
11
21
PR 76-106
64 63
70
89
83
77
91
88
104
86
BLOOD PRESSURE CHART

50
70
90
110
130
150
170
6/30/14 7/1/14 7/2/14 7/3/14
Systolic Diastolic Heart Rate
LAB RESULTS


REFERANCE RANGE CLINICAL VALUE
30/6/14 1/7/14 2/7/14
Hb 11.5-16.5g/100ml
11.1 7.8
WBC 4-11x 10/L
15.47 16.36 17.63
Hct 40-50
26.5 24.6
MCV 83-101
91.8
MCH 26.5-31.5
29.1
PLATELET 150-410
315 286 254
HEMATOLOGY
Arterial blood gas
ACTUAL RANGE CLINICAL VALUE
pH 7.35-7.45
7.239
pCO2 35-45mmHg
34.8
pO2 80-90mmHg
41.3
HCO3 22-26mmHg
14.8
So2 % 96-97%
96
REFERENCE RANGE CLINICAL VALUE
PT 10-13.5 s 13.6
INR <1.5 1.06
APTT 26-42 25.6
APTT RATIO 1.5-2.5 1.88
COAGULATION
REFERENCE RANGE CLINICAL VALUE
30/6 01/7
Na 135-145mmol/L 138 133
K 3.5-5.0mmol/L 4.5 3.8
Cl 96-107mmol/L 97 97
Cr 64-122umol/L 65.47 76
Urea 1.7-8.3mmol/L 5.02 5.7
Mg 0.7-1.3mmol/L 0.82 0.8
Phosphate 0.8-1.5mmol/L 1.66 1.6
Calcium 2.1-2.6mmol/L 2.17 2.20
RENAL PROFILE

LIVER PROFILE
REFERENCE
RANGE
CLINICAL
VALUE
Total Protein 66-83 85 g/L
Albumin 35-52 36 g/L
Alp 30-120 52 IU/L
Alt 0-50 1 IU/L
Total Bilirubin 5-21 14 mol/L
Initial Diagnosis of AAA
38% patients AAAs initially detected by physical
examination.
2
62% found incidentally on x-ray studies done for other
indications
AAAs detected by physical examination had lower
BMIs but there was no difference in AAA size
Obese patients had only 15% of AAAs detected, and
only 33% were palpable.


Rupture Risk of AAA
AAA diameter (cm) Rupture rate (% per year)


Less than 4 cm diameter 0%

4-5 cm diameter 0.5-5%

5-6 cm* diameter
3
3-15%

6-7 cm diameter 10-20%

7-8 cm diameter 20-40%

More than 8 cm diameter 30-50%
Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery

COMPLICATIONS OF RUPTURED AAA
8
Hemorrhage and shock
Renal Failure
Anoxic Encephalopathy
Ischemic Colitis (30%)
Limb ischemia
Pulmonary failure
Countless others

Brady AR, et al., 2004
MANAGEMENT
Goal : Slow the rate of AAA growth such that it
does not reach the threshold for rupture
within the patients lifetime.
8


Pre and post endovascular
repair
60 : 13
70 : 10
80 : 6
MEDICATION CHART
30/7 1/7 2/7 3/7
IV Tramal 50mg
IV Metoclopromide 10mg Stat &
PRN
Iv Ranitidine 50mg Stat & TDS
Iv Pantoprazole 40mg OD
IV Tranexamic Acid 2g Stat &
1g TDS
IV Morphine 2.5mg Stat
IV Vitamin K 30mg Stat & 10mg
OD
DISCUSSIONS :
1. STATINS
9
:
No records for cholesterol level.
Statin use was associated with a significant
decreased rate of AAA growth.
4

2. ACE INHIBITORS
10
:
Use of ACE-I was less frequent in patients
who presented to hospital with ruptured AAA.

3. BETA BLOCKERS
11
:

Patients receiving a beta-blocker had slower
rate of AAA growth.*
Patients receiving propranolol had significant
difference in AAA growth rate.

03/07/14
Visited by Consultant. Referred to HKL for immediate repair.
T/O HKL.
02/07/14
Persistent pain with few episodes of hypotension.
CT A Active leaking AAA
01/07/14
Persistent abdominal pain with N/V. Managed
with painkillers and anti-emetics.
CT A Non-leaking AAA
30/6/14
Chief complaint : abdominal pain
with pulsatile mass.
US ABD - AAA
CONCLUSION
25
REFERENCES :
1. Lederle FA, Wilson SE, Johnson GR, et al. N Engl J Med 346:1437, 2002.
2. Role of physical examination in detection of abdominal aortic aneurysms.
Surgery 1995 Apr;117(4):454-7 Chervu A; Clagett GP; Valentine RJ; Myers
SI; Rossi PJ
3. Joint Council of the American Association for Vascular Surgery and Society
for Vascular Surgery (Brewster DC, Cronenwett JL, Hallett JW, et al. Vasc
Surg 37:1106, 2003
4. http://my.clevelandclinic.org/disorders/aneurysms/hic_abdominal_aortic_
aneurysm.aspx
5. http://emedicine.medscape.com/article/463354-overview
6. http://www.mayoclinic.org/aortic-aneurysm/
7. http://www.nlm.nih.gov/medlineplus/ency/article/000162.htm
8. Brady AR, et al., 2004, Abdominal aortic aneurysm expansion - Risk factors
and time intervals for surveillance, Circulation, Vol:110, ISSN:0009-7322,
Pages:16-21

9. Schouten O, et al. Statins are associated with a reduced infrarenal
abdominal aortic aneurysm growth. Eur J Vasc Endovasc Surg.
2006;32:2126.
10. Hackam DG, et al. Angiotensin-converting enzyme inhibitors and aortic
rupture: a population-based case-control study. Lancet. August 19,
2006;368:65965.
11. Leach SD, Toole AL, Stern H, et al. Effect of beta-adrenergic blockade on
the growth rate of abdominal aortic aneurysms. Arch Surg 1988;123:606.
Not to be confused with . . .
A Cute
Abdomen