Abdominal Aortic Aneurysm Presenting Research Articles

A case of abdominal aortic aneurysm presenting as symptomatic disseminated intravascular coagulation treated with endovascular aneurysm repair and postoperative administration of Nafamostat mesylate

BackgroundCases of abdominal aortic aneurysm discovered as purpura on the extremities with disseminated intravascular coagulation (DIC) are rare. The number of currently established strategies for the control of DIC with aortic aneurysm is limited.Case presentationAn 85-year-old woman was referred to the hematology department because of purpura on her shoulder and thigh. Enhanced fibrinolytic-type DIC was diagnosed by a blood test. Enhanced computed tomography (CT) revealed 60-mm abdominal aortic and 42-mm right common iliac aneurysms. We performed endovascular aneurysm repair (EVAR) and coiling of the right internal iliac artery with postoperative administration of Nafamostat mesylate. The patient promptly recovered from DIC, and the purpura gradually disappeared.ConclusionsWe safely performed EVAR with postoperative administration of Nafamostat mesylate for an abdominal aortic aneurysms that presented as symptomatic DIC.

Hostile neck anatomy contributes to higher rates of reintervention following endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysms (AAA) presenting with hostile neck anatomy can represent a challenge in surgical decision-making. We hypothesized that, patients who require reinterventions have higher rates of compromised neck anatomy at initial presentation and may indicate a need for altered surveillance paradigm. Patients presenting with ruptured AAA to a single tertiary care institution from 2014 to 2021 were retrospectively reviewed. Those treated with infrarenal EVAR, with no prior aortic surgeries, and with available pre-operative computed tomography (CT) scans were included. Demographics, timing and type of reintervention, follow-up, and survival were collected. CT scans were assessed for hostile neck anatomy via measurements of diameter, length, angle, taper, bulge, calcification, and thrombus. Demographics, comorbidities, and neck anatomy of those with and without reintervention were compared using Fischer's Exact and Student's T-test. Survival was analyzed via Kaplan-Meier and log-rank test. Eighty-nine patients were available for analysis, 37 of which met inclusion criteria. Intraoperative death occurred in 3 patients (8.1%) and 1 patient (2.7%) was intraoperatively converted to an open repair. Thirty-day and 1-year survival were 97% and 91%, respectively. The reintervention rate was 30% (n = 10), occurring at a median of 200days (18-2053days) after the index operation. All patients requiring reintervention met hostile neck criteria (p = .002) and had a statistically higher number of hostile neck criteria (1.80 vs 0.87, p = .03). Thirty percent (n = 3) of patients that received a reintervention had neck diameter greater than 3cm, compared to zero patients in the non-reintervention group (p = .022). Proximal reinterventions (n = 5) had statistically higher neck diameters and neck angle compared to the non-reintervention group. Infrarenal rEVAR is effective at preventing acute mortality despite specific anatomic considerations that may contribute to the higher reintervention rates, and therefore those parameters ought to be considered when following patients in the post-intervention period.

Rare Presentation of Aortic Aneurysm: A Diagnostic Challenge

This case report highlights a rare presentation of abdominal aortic aneurysm, which posed a diagnostic challenge due to its atypical clinical manifestations. The patient initially presented with vague symptoms of renal colic and underwent a comprehensive evaluation, including imaging studies, to establish the diagnosis. Through a multidisciplinary approach and careful analysis of the diagnostic findings, a rare form of aortic aneurysm was identified. This case emphasizes the importance of considering unusual presentations of aortic aneurysms and the need for thorough investigation to ensure accurate diagnosis and appropriate management. Keywords: aortic aneurysm, rare presentation, diagnostic challenge, multidisciplinary approach

Physical Rehabilitation of Patient with Infrarenal Section Abdominal Aortic Aneurysm Presenting with Hydrocele and Inguinal Hernia: A Case Report

Infrarenal Abdominal Aortic Aneurysm (AAA) is an abnormal dilation of distal abdominal aorta. The risk factors are age older than 60 years, smoking, hypertension and caucasian ethnicity. Testicular pain is an uncommon clinical presentation. There is a high prevalence of inguinal hernia in patients with infrarenal AAA. The purpose of the present case report is to describe the functional activity limitation in a patient affected by an infrarenal AAA presenting as a symptom of inguinal hernia and groin pain despite successful infrarenal AAA repair with aortofemoral bypass surgery and bilateral inguinal hernia repair. A 62-year-old male patient, presented with pain in the groin region and mild swelling over the scrotal region, which was severely limiting his activities of daily living. A Computerised Tomography (CT) angio abdomen revealed a fusiform aneurysm on the distal abdominal aorta and a saccular aneurysm of bilateral common iliac arteries. Given the minimum of four days of referral waiting time to receive treatment for infrarenal AAA, the patient underwent surgery and was followed by the postoperative physiotherapy intervention. The rehabilitation programme started five days postsurgery. The treatment goals directed mainly decreasing postoperative pulmonary complications and improving functional mobility. The present case report contributes new light on the possible pathogenesis and timely management. It reports the unexpected and unusual presentation of the disease and unveiling the link between the presentation of infrarenal AAA and inguinal hernia and hydrocele.

Stable Treatment and Outcomes Over a Decade of Increasingly Complex Urgent Abdominal Aortic Aneurysm Presentation

Endovascular aneurysm repair (EVAR) has been used increasingly for urgent management of symptomatic or ruptured abdominal aortic aneurysms (rAAA) and therefore has disseminated increasingly from high-volume aortic centers to community hospitals. Given this, we hypothesized that the presentation and management of patients with rAAA have changed over the past decade at a high-volume aortic center to more complex, including an increase in those not offered repair.

Patient-Tailored Approach for Diagnostics and Treatment of Mycotic Abdominal Aortic Aneurysm

The existing literature on mycotic aortic aneurysm is scarce and focuses on treatment. This study evaluates the clinical characteristics, diagnostics, treatment and outcome of patients with a mycotic abdominal aortic aneurysm treated in a tertiary referral center. A retrospective cohort study was conducted including all patients with a proven mycotic abdominal aortic aneurysm admitted between May 2010 and July 2020. Primary outcome was mortality and secondary outcome included complications such as vascular graft/endograft infection. Twenty-four patients with a mycotic abdominal aortic aneurysm were included. Patients had a mean age of 68 ± 9 years and 20 (83%) were male. Thirteen patients (57%) had positive preoperative blood cultures. Streptococcus pneumoniae was most frequently isolated by blood culturing, pus, and vascular, or perivascular tissue cultures (17%). In 19 (83%) patients the mycotic abdominal aortic aneurysm was located infrarenally, in three (13%) patients suprarenally, and in one (4%) patient juxtarenally. Median follow-up was 20 (7-42) months. In 8 patients (33%) vascular graft and or endograft infection was diagnosed after surgical repair. Ten (42%) patients died during the follow-up period. The main causes of death were vascular graft/endograft infection-related (n=4) and rupture of the mycotic abdominal aortic aneurysm (n=3). No patient characteristics could be identified as predictive for mortality. This study shows a large variation in presentation, diagnostic approaches, and surgical and antibiotic treatment of mycotic abdominal aortic aneurysm. The detailed information about the diagnostic approaches to this rare disease and its antibiotic and/or other treatment contributes to existing knowledge of mycotic abdominal aortic aneurysm. Because of the individual variation patients should be discussed in a multidisciplinary team with a vascular surgeon, infectious disease specialist, and clinical microbiologist.

Successful Endovascular Repair for Abdominal Aortic Aneurysm Presenting as Aortoduodenal Syndrome.

Aortoduodenal syndrome is a rare duodenal obstruction caused by an abdominal aortic aneurysm. Current treatment involves open aneurysmal repair according to the theory that this procedure releases the duodenum from mechanical compression. However, the mechanism of duodenal blockage remains unclear and reports of endovascular aneurysm repair (EVAR) for aortoduodenal syndrome are quite rare. We report our successful case of EVAR for aortoduodenal syndrome without aneurysmal shrinkage and discuss the mechanism of duodenal obstruction.

Association of Sex With Repair Type and Long-term Mortality in Adults With Abdominal Aortic Aneurysm

Sex-based differences exist in the prevalence and clinical presentation of abdominal aortic aneurysm (AAA). However, it is unclear if sex is associated with AAA repair type and long-term mortality. To investigate whether a sex-related difference exists in mortality risk after AAA repair owing to differences in repair type. This cohort study uses data from the Vascular Quality Initiative, a national clinical registry, and Medicare claims to investigate endovascular and surgical repair procedures performed between January 1, 2003, and September 30, 2015, in patients aged 65 years or older with AAA. The data were analyzed from October 1, 2018, to November 19, 2019. Sex of the patient. Endovascular (EVR) or open surgical AAA repair type and subsequent long-term, all-cause mortality. In this cohort study of 16 386 patients, 12 757 (77.9%) were men and 3629 (22.1%) were women. Women were more likely than men to be older (mean [SD] age, 77 [6.5] years vs 75 [6.6] years; P < .001), active smokers (33% vs 28%; P < .001), and to have smaller aneurysms (mean [SD] diameter, 57 [11.7] mm vs 59 [17.7] mm; P < .001). Surgical AAA repair was performed in 27% (983 of 3629) of women compared with 18% (2328 of 12 757) of men (P < .001). After inverse probability weighting for risk adjustment, women were more likely to receive open surgical repair than EVR repair (risk ratio, 1.65; 95% CI, 1.51-1.80). The 10-year unadjusted survival rate after EVR repair was 14% lower in women than in men (23% vs 37%; log-rank P < .001), but the rates were comparable after open surgical repair (36% in men vs 32% in women; log-rank P = .22). Risk-adjusted analysis showed that women were associated with higher mortality rates after EVR repair (hazard ratio, 1.13; 95% CI, 1.03-1.24), whereas both men and women had a similar risk of death after open surgical repair (hazard ratio, 0.94; 95% CI, 0.84-1.06). After further stratification by symptom severity, higher risk of mortality among women was limited to elective EVR and open surgical repair for ruptured AAA. In this study, women were 65% more likely than men to undergo open surgical repair. After EVR repair, women were 13% more likely to die than men, although no sex-based difference in mortality was found after open surgical repair. The differential treatment benefit of EVR repair in women is concerning given the shift toward an EVR-first approach to AAA repair.

Abstract MP24: Women Experience Higher Rates of Surgical Repair and Mortality for Abdominal Aortic Aneurysm

Background: It is unknown how gender disparities in the clinical presentation of abdominal aortic aneurysm (AAA) affects AAA repair type and long-term survival. We assessed the hypothesis that compared to men, women face a higher risk of death after AAA repair due to differences in demographics, disease severity, and repair type. Methods: We analyzed all endovascular (EVAR) and open surgical (OPEN) AAA repairs from 2003-2015 in the Vascular Quality Initiative-Medicare linked registry. Using inverse probability weighting, we balanced patient demographics, comorbidities, and disease severity among men and women. Then, we evaluated the effect of gender on AAA treatment and subsequent survival using Poisson and Cox regression, respectively. Results: In this cohort (n=16,085), patients undergoing EVAR (79%) or OPEN (21%) had up to 12 years of follow-up. Women comprised 22% of the cohort and were older (mean age 77 ±6.6 vs. 75 ±6.5 years, p&lt;0.001), less likely to smoke (28% vs. 33%, p&lt;0.001), and had smaller aneurysms (58.7 ±18.5 mm vs 56.5 ±12 mm) than men (Figure). After balancing key risk factors, women were 1.6 times more likely to receive OPEN vs. EVAR (RR: 1.59, 95% CI: 1.46-1.72). The 12-year mortality rate after AAA repair was 74% in men vs 84% in women. After adjustment, women faced a 12% increased risk of death (HR: 1.12, 95% CI: 1.04-1.21). Sub-analysis by repair type revealed a gender discrepancy among EVAR patients, where women experienced poorer survival (HR: 1.18, 95% CI: 1.09-1.29), while men and women faced an equal risk of death after OPEN (HR: 1.00, 95% CI: 0.90-1.12). Conclusion: In conclusion, women were 1.6 times more likely to undergo OPEN repair than men, despite balancing key baseline AAA risk factors associated between men and women. After EVAR, women were 12% more likely to die than men, though no gender-based morality difference exists following OPEN repair. The differential treatment benefit of EVAR in women is concerning given the trend toward an endovascular-first treatment approach to AAA.

Aneurysm Morphology Is a More Significant Predictor of Survival than Hardman's Index in Patients with Ruptured or Acutely Symptomatic Abdominal Aortic Aneurysms

Scoring systems such as Hardman's index are used to predict outcomes and stratify patients with ruptured abdominal aortic aneurysm (RAAA) or acutely symptomatic abdominal aortic aneurysm (SAAA) to active treatment or palliation. Aneurysm morphology is not included in these scoring systems. The aim of this study was to assess whether aneurysm morphology was an independent predictor of survival. Consecutive patients admitted from January 2006 to March 2017 with emergency presentation and primary diagnosis of abdominal aortic aneurysm were identified. Patients were stratified by age, gender, mode of presentation (RAAA versus SAAA), Hardman's Index, aneurysm morphology (suitability for endovascular aneurysm repair [EVAR]), and the procedure performed (endovascular versus open). Multivariable logistic regression analysis was used to determine predictors of survival. A total of 346 patients were included (RAAA: 250, SAAA: 96). Median age of patients was 75years (range: 44-96); 284 (79%) were men and 75 (21%) were women. Three hundred twenty-five patients underwent preoperative computed tomography (CT) scan of these 156 (48%) fulfilled conservative instructions for use (IFU) for EVAR and another 64 (20%) were within the liberal IFU for EVAR. Median Hardman Index was 1 (range 0-5). Age (odds ratio [OR]: 1.72 [95% confidence interval {CI}: 1.15-2.23] [P<0.001]), mode of presentation [(OR: 2.05 (95% CI: 1.45-3.31) (P<0.001)], and aneurysm morphology being within conservative IFU for EVAR [(OR: 1.61 (95% CI: 1.08-2.03) (P=0.02)], modality of repair (open versus EVAR), (OR: 0.81 [95% CI: 0.67-0.92], [P<0.001]) were independent predictors of survival. Hardman's index (OR: 0.86 [95% CI: 0.69-1.11], [P=0.16]) and gender (OR: 1.15 [95% CI: 0.83-1.32], [P=0.24]) were not. Aneurysm morphology is a significant predictor of survival after RAAA. This information should be included in any scoring system.

Atypical Presentation of Abdominal Aortic Aneurysm

Atypical Presentation of Abdominal Aortic Aneurysm

A Case Report of Abdominal Aortic Aneurysm presenting as an Inguinal Mass

A Case Report of Abdominal Aortic Aneurysm presenting as an Inguinal Mass

Unusual presentation of silently growing abdominal aortic aneurysm causing biliary obstruction

Biliary obstruction is a rare presentation of abdominal aortic aneurysm (AAA). The most common symptoms of AAA are abdominal or back pain and limb ischaemia from thromboembolism. We report a...

Risk of abdominal aortic aneurysm (AAA) among male and female relatives of AAA patients

Sex affects the presentation, treatment, and outcomes of abdominal aortic aneurysm (AAA). Although AAAs are less prevalent in women, at least in the general population, women with an AAA have a poorer prognosis in comparison to men. Sex differences in the genetic predisposition for aneurysm disease remain to be established. In this study we investigated the familial risk of AAA for women compared to men. All living AAA patients included in a 2004-2012 prospective database were invited to the multidisciplinary vascular/genetics outpatient clinic between 2009 and 2012 for assessment of family history using detailed questionnaires. AAA risk for male and female relatives was calculated separately and stratified by sex of the AAA patients. Families of 568 AAA patients were investigated and 22.5% of the patients had at least one affected relative. Female relatives had a 2.8-fold and male relatives had a 1.7-fold higher risk than the estimated sex-specific population risk. Relatives of female AAA patients had a higher aneurysm risk than relatives of male patients (9.0 vs 5.9%, p = 0.022), corresponding to 5.5- and 2.0-fold increases in aneurysm risk in the female and male relatives, respectively. The risk for aortic aneurysm in relatives of AAA patients is higher than expected from population risk. The excess risk is highest for the female relatives of AAA patients and for the relatives of female AAA patients. These findings endorse targeted AAA family screening for female and male relatives of all AAA patients.

Anatomic Characteristics of Abdominal Aortic Aneurysms Presenting With Delayed Rupture Status Post EVAR

Anatomic Characteristics of Abdominal Aortic Aneurysms Presenting With Delayed Rupture Status Post EVAR

Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England

Prior studies of gender differences in abdominal aortic aneurysm (AAA) repair suggest there may be differences in presentation, suitability for endovascular aneurysm repair (EVAR), and outcomes between men and women. We used the Vascular Study Group of New England database to identify all patients undergoing EVAR or open AAA repair. We analyzed demographics, comorbidities, and procedural, and perioperative data. Results were compared using the Fisher exact test and the Student t-test. Multivariable logistic regression and Cox proportional hazards modeling were performed to identify predictors of mortality. We identified 4026 patients (78% men) who underwent AAA repair (54% EVAR). Women were less likely than men to undergo EVAR for intact aneurysms (50% vs 60% of intact AAA repair; P < .001) but not for ruptured aneurysms (26% vs 20%; P = .23). Women were older (median age, 75 vs 72 years for intact; P < .001; 78 vs 73 years for rupture; P < .001) with smaller aortic diameters (57 vs 59 mm for elective; P < .001; 71 vs 79 mm for rupture; P < .001). Arterial injury was more common in women (5.4% vs 2.7%; P = .013) among patients undergoing EVAR for intact aneurysms. Women stayed in the hospital longer (4.3 vs 2.7 days; P = .018) and had lower odds of being discharged home, even after adjusting for age. Among patients undergoing open repair for intact aneurysms, women more frequently experienced leg ischemia/emboli (4% vs 1%; P = .001) and bowel ischemia (5% vs 3%; P = .044). Women had higher 30-day mortality after OAR for intact (4% vs 2%; P = .03) and rupture (48% vs 34%; P = .03) repairs. However, 30-day mortality after EVAR was similar for intact (1% in men vs 1% in women; P = .57) and rupture (29% in men vs 27% in women; P > .99) repairs. Late survival was worse in women than men only for patients undergoing open repair of ruptured aneurysms (hazard ratio, 1.8; 95% confidence interval, 1.0-3.1; P = .04). After controlling for age, type of repair, urgency at presentation (ie, elective/intact vs ruptured), comorbidities, and other relevant risk factors, gender was not predictive of 30-day or 1-year mortality. Women with AAAs are being treated at older ages and smaller AAA diameters and are undergoing rupture repair at smaller diameters than men. Women are more likely to experience perioperative complications as a result of less favorable vascular anatomy. Age >80 years, comorbidity, presentation, and type of repair are more important predictors of mortality than gender.

Abdominal aortic aneurysm presenting as a claudication.

Back pain and radiating pain to the legs are the most common symptoms encountered in routine neurosurgical practice and usually originates from neurogenic causes including spinal stenosis. The clinial symptoms are often confused with symptoms of peripheral neuropathy, musculo-skeletal disease and vascular disease in elderly patients. Because it is not easy to distinguish out the cause of symptoms by only physical examination, routine spinal MRI is checked first to rule out the spinal diseases in most outpatient clinics. Although it is obvious that spinal MRI is a very strong tool to investigate the spinal circumferences, most spine surgeons ignore the importance of looking at all aspects of their imaging and of remembering the extra-spinal causes of radiculopathy. A 68-year-old man who presented with a sudden aggravated both leg claudication. Although his symptom was mimicked for his long standing neurogenic claudication due to spinal stenosis diagnosed previously, abdominal aortic aneurysm(AAA) was found on routine lumbar MRI and it was repaired successfully. We emphasize to spinal surgeons the importance of remembering to look wider on routine MRI images when considering differential diagnoses in the outpatient clinic and to remember the extra-spinal causes of radiculopathy, especially when encountering in elderly patients.

Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome

Acute aortic occlusion is an uncommon vascular emergency that can present with predominantly neurologic symptoms owing to spinal cord ischemia. We describe a 62-year-old woman who experienced acute thrombosis of an abdominal aortic aneurysm that initially presented as cauda equina syndrome. She was treated operatively with an axillary bifemoral bypass. Our case report is followed by a discussion of acute aortic occlusion.

Primary Aortoduodenal Fistula in a Patient With Pararenal Abdominal Aortic Aneurysm

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.

Acute thrombosis of abdominal aortic aneurysm presenting with lower limb ischaemia

Acute thrombosis of abdominal aortic aneurysm presenting with lower limb ischaemia