Case of the Month September 2015, Page 2

Ruptured infrarenalabdominal aortic aneurysm with hemorrhage extending into the left retroperitoneum, and along the left pelvic sidewall into the pelvis.

 

Follow Up

The ED was immediately called with the results.

The patient was evaluated by vascular surgery, whom had known the patient in the past and had advised him previously that repair was essential, but the patient had always refused surgical repair.  He was again advised that immediate repair was vital to survival.

The patient clearly expressed his wishes not to have any surgical intervention and his desire to pass in peace.

His family members were present at bedside, he was given supportive therapy and his blood pressure gradually decreased until he passed.

Progression of Imaging

The following are selected images from CTs acquired over the preceding 6 years demonstrating the pathogenesis of the aortic aneurysmal rupture.

For larger images, please click on: End Stage 3 (2009), End Stage 4 (2010), End Stage 5 (2014), End Stage 6 (Current), End Stage 7 (2009), End Stage 8 (2010), End Stage 9 (2014) and End Stage 10 (Current).

Below 2009

Below 2010

Below 2014

Below Current

Below 2009

Below 2010

Below 2014

Below Current

Vascular Surgery Evaluation Prior to Patient's Demise

  • Vascular surgery followed the patient since the original CT of 2009 demonstrating the presence of the aneurysm measuring 5.3 cm.
  • The patient was advised to undergo surgical repair since the aneurysm was close to the renal arteries and could compromise renal perfusion, however he refused.
  • The aneurysm was stable until it dilated to 7 cm on a subsequent CT study in 2014 at which time he was again advised to undergo surgical repair but continued to refuse despite repeated warning of the threat to his life.

Abdominal Aortic Aneurysm (AAA) epidemiology, diagnosis, prevention and treatment

  • The normal abdominal aortic diameter is 3.0 cm.
  • Aortic aneurysm develop due to weakening in the strength of the elastic tissue in the aortic wall, most often due to normal aging, hypertension and atherosclerotic disease.
  • An aneurysm is diagnosed when the dilatation exceeds 1.5 times the normal diameter.
  • AAA cause approximately 15,000 deaths annually, accounting for 1-2% of all male deaths over the age of 65, will affect up to 8% of people over 65 and is the 17th leading cause of death.
  • AAA usually arise in the sixth decade of life and are more common in men than women.
  • The risk factors for AAA include active tobacco smoking, hypertension, hyperlipidemia and first degree family history of AAA.\
  • A large screening study demonstrated that tobacco smoking accounted for 75% of all AAAs 4.0 cm or greater in diameter and is strongly associated with current smoking and years of smoking but decreases in risk proportional to time since quitting smoking.
  • AAA measuring between 4 to 5. 5 cm tend to dilate 0.3 cm per year. Larger aneurysms dilate faster, smaller aneurysms dilate slower. Active smoking is correlated with faster dilatation rates regardless of size. Risk of rupture ranges from 1-10% per year with an aneurysmal diameter of 5 cm and 25% when 6 cm or larger. Rupture rates are higher in woman than men although the incidence of AAA is higher in men.
  • Diagnosis is difficult as most AAA are asymptomatic. Diagnosis is usually  made incidentally.
  • AAA rupture is fatal in up to 80% of cases.
  • Options of AAA management include watchful waiting, open surgery and endovascular repair – Surgical mortality can be as high as 2-6%
  • The U.S. Preventive Services Task Force (USPSTF)  recommends screening with an abdominal ultrasound for detecting asymptomatic AAA in patients between 65-75 years old with a history of smoking.
  • Surgical repair is the standard of care.
  • Endovascular repair reduces operative morbidity, shorter hospital stays and faster recovery time. However it can be more expensive.\
  • A vascular surgery consultation  is recommended for anyone with a 5.5 cm or greater AAA.

Works Cited

  • Frank A. Lederle, MD. In the clinic Abdominal Aortic Aneurysm. 2009 American College of Physicians. Ann Intern Med. 2009;150(9):ITC5-1. doi:10.7326/0003-4819-150-9-200905050-01005
  • Patrick T. O’Gara, MD. Aortic Aneurysm. Circulation. 2003;107:e43-e45. 2003 American Heart Association, Inc. DOI: 10.1161/01.CIR.0000054210.62588.ED
  • P.E. Norman, DS; J.T. Powell, MD. Abdominal Aortic Aneurysm The Prognosis in Women Is Worse Than in Men. Circulation. 2007;115:2865-2869. 2007 American Heart Association, Inc. DOI: 10.1161/CIRCULATIONAHA.106.671859
  • Abdominal Aortic Aneurysms. Copyright © 2015 Society of Interventional Radiology.  http://www.sirweb.org/patients/abdominal-aortic-aneurysms/
< Previous Page Visit our Case of the Month Archive