Diagnosis
Ruptured aortic aneurysm
A life-threatening emergency where a weakened aneurysmal aortic wall tears, causing massive internal bleeding and disrupting blood flow.
Aneurism: An irreversible dilatation to at least 1.5 times its normal caliber
True aneurysm: Involves all layers of the wall
False aneurysm (pseudoaneurysm): Involves only a portion of the wall
Etiology
Cause
Degenerative: atherosclerosis
Mycotic/infected
Connective tissue disease: Marfans syndrome, Ehlers-Danlos, medial necrosis
Pseudoaneurysm: iatrogenic (catheter, anastomosis), trauma, dissection
Poststenotic: thoracic outlet syndrome, aortic/pulmonary valvular stenosis, coarctation of aorta
Pathophysiology [8mb]
Law of Laplace: wall stress = (Pressure x Radius) / (2 x wall thickness)
Risk of rupture is decided by:
The size (radius)
Rate of expansion
Hypertension (pressure)
Aneurysm shape: fusiform = low risk, saccular = average, eccentric = high risk
Position and geometry
Presence of intraluminal thrombus
Presence of wall calcification
Aortic wall thickness
Degree of wall inflammation
Rupture: Force per unit area within the vessel exceeds the tensile wall strength
Posterolateral wall rupture --> contained bleeding within the retroperitoneal space --> patient may survive for treatment
Clinical manifestation:
Hyperacute abdominal/back pain
Hypotension and tachycardia
Pulsatile abdominal mass
Grey-Turner's sign: Ecchymosis involving the flanks
Risk factors [xgv]
Age
Gender: female = higher risk of rupture
Smoking
Family history
Hypertension
Diameter: Risk of rupture related to aortic wall tension (Laplace law)
30-55mm: 1.6% annual rupture risk [pbz]
50-59mm: 3.5% annual rupture risk [iso]
60-70mm: 10-20% annual rupture risk [2va]
70-80mm: 30-40% annual rupture risk [2va]
>80mm: 30-50% annual rupture risk [2va]
Complications [xgv]
Death (30% for rAAA)
Pneumonia (5%)
Myocardial infarction (2-5%)
Groin infection (<5%)
Graft infection (<1%)
Colon ischemia (<15-20%)
Renal failure
Incisional hernia (10-20%)
Amputation
Impotence in males
Lymphocele in groin (~2%)
Late graft-enteric fistula
Endograft infection
Limb occlusion leading to acute limb ischemia
Endoleak after endovascular repair
Type I: Blood flow into the aneurysm sac due to incomplete seal
Type Ia for proximal fixation problems
Type Ib for distal fixation problems
Type II: Backflow from collateral vessels (lumbar or inferior mesenteric artery)
Type III: Blood flow into the aneurysm sac due to inadequate overlapping graft joints or rupture of the graft fabric
Type IV: Blood flow into the aneurysm sac due to the porosity of the graft fabric
Epidemiology
Incidence per 100.000 [qti][vzd][46c][svc][akr][vpp][vqu][fys][k1a]
Symptoms & findings
Symptoms
Coma, Cullen's sign, Cyanosis, Decreased consciousness, Diastolic murmur, Dysphagia, Dyspnea, Fox's sign, Grey Turner's sign, Heart murmur, Hematemesis, Hemiplegia, Hemoptysis, Hoarseness, Hypotension, Nausea, Pallor, Paralysis, Paresthesia, Pulselessness, Seizure, Stridor, Syncope, Systolic murmur, Tachycardia, Tachypnea, Thrill, Unconsciousness, Vascular murmur
Clinical findings
Anemia, Elevated CRP, Elevated Lactate, Hemoperitoneum, Hemothorax, Mediastinal widening, Shock
Anamneses
None listed.
Localized findings
Approach
Blood test
Blood gas
Ultrasound abdomen
CT abdomen
Angiography
MRI abdomen
Chest X-ray
CT thorax
Echocardiography
Treatment
Initial treatment: [xgv]
Airways
Breathing: O2
Circulation (sBP: 100-120 mmHg): Fluid resuscitation, blood transfusion
Pain management: IV morphine
Endovascular aortic repair (EVAR): the preferred treatment for rAAAs if it is anatomically feasible
Mortality: 20-35% (30 day), 30-41% (1-year) [zbw][ftg][8ng][g3r][r2y]
Open surgical repair:
Mortality: 24-31% (30 day), 35-44% (1-year) [zbw][ftg][8ng][g3r][r2y]
Differential diagnoses
Acute pancreatitis, Appendicitis, Cholelithiasis, Diverticulitis, Gastritis, Gastrointestinal obstruction, Inguinal hernia, Myocardial infarction, Perforated ulcer, Pneumothorax, Spinal disc herniation, Urinary tract infection, Urolithiasis
References
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[2] http://emedicine.medscape.com/article/756735 (2014-01-02); [Medscape]
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