Infrarenal abdominal aortic aneurysms

Opinion statement Screening programs should be instituted to identify patients with small asymptomatic abdominal aortic aneurysms (AAAs) in the community. Screening for AAAs reduces the rate of aneurysm rupture and reduces death from aneurysmal disease in the population. The indications for aneurysm surgery have been defined by two recent randomized clinical trials. Patients with symptomatic or ruptured AAAs should be treated by urgent or emergency surgery. Patients with asymptomatic AAAs should not undergo surgical repair until the aneurysm exceeds 5.4 cm in maximum diameter. The most appropriate surgical option for the majority of patients with AAAs is conventional inlay grafting. This may be approached transperitoneally, although the retroperitoneal approach is favored for inflammatory or juxtarenal aneurysms. Conventional aneurysm repair may be performed with acceptable mortality and good long-term durability in specialized centers with a high volume of cases. The place of endovascular aneurysm repair remains to be defined. Endovascular repair is the best option in high-risk patients with suitable aneurysm morphology. The questions over the long-term durability of endovascular aneurysm surgery in preventing aneurysm rupture make it unsuitable for young patients. Randomized trials will define the indications for this technique. Endovascular surgery is likely to become the most appropriate treatment for ruptured aneurysms in the next decade.     

Inflammatory abdominal aortic aneurysm

A 58-years-old man, with no medical past history, was examined for abdominal pain and weight loss. An enlarged kidney could be palpated, and abdominal echography showed left hydronephrosis due to ureteral compression by abdominal aortic aneurysm. Laboratory data showed an inflammatory syndrome. CT scan suggested the diagnosis of inflammatory abdominal aortic aneurysm. The use of corticosteroids brought about the regression of the symptoms and the resolution of the ureteral obstruction, permitting aneurysmectomy and prosthesis replacement without ureterolysis. This report shows the interest of preoperative radiological diagnosis of the inflammatory character of abdominal aneurysm. For uncomplicated cases, preoperative treatment using corticosteroids could allow partial regression of the periaortic inflammation and easier surgical repair.     

Syphilitic abdominal aortic aneurysm

A case report of a syphilitic aortic aneurysm in a 37-year-old male, presenting as upper abdominal pain accompanied by a pulsatile abdominal mass, is discussed.     

Focal atherosclerotic abdominal aortic stenosis

We report a case of a 54-year-old woman presenting a symptomatic focal atherosclerotic abdominal aortic stenosis. Computed tomographic angiography allowed to study the lesion, the abdominal aorta and its main branches. The patient was treated via an endovascular approach using a covered stent. The postoperative course was uneventful and the patient was asymptomatic with a patent reconstruction after 18 months. Improvement in endovascular technology has totally modified the treatment of focal atherosclerotic abdominal aortic stenosis. However, many technical points remain to be determined including the necessity of systematic stenting, the type of stent to use, and the steps of the procedure.     

Management of abdominal aortic aneurysms

Optional statement Abdominal aortic aneurysms (AAAs) are a lethal disease. Ultrasound is the modality of choice for screening patients for AAAs. It is reasonable to screen patients over age 60, particularly men, women with cardiovascular risk factors, smokers, and patients with a family history of AAAs. Patients with small (< 5.5 cm) AAAs should be followed with serial ultrasound. Medical management should focus on treating comorbidities, particularly those that put patients at risk for other cardiovascular diseases. Smoking cessation is mandatory in these patients. Patients with large or symptomatic AAAs should be evaluated for surgery; this includes careful imaging of the abdomen, aggressive treatment of comorbidities, and perioperative β blockade. Endovascular repair has lower short-term morbidity compared with conventional open repair. Trials assessing long-term results are in progress. Basic science and translational research focusing on the underlying pathogenesis of AAAs will likely pave the way for medical therapies in the future.     

Posttraumatic infrarenal abdominal aortic pseudoaneurysm

Posttraumatic abdominal aortic pseudoaneurysm is a rare lesion. To date, fewer than 30 cases have been reported in the literature, with most of those cases involving the suprarenal aorta. Infrarenal posttraumatic abdominal aortic pseudoaneurysm following abdominal trauma has been reported in only 6 other cases. We observed such a lesion in a 62-year-old man 15 years after blunt abdominal trauma inflicted in a car accident. Back pain was the presenting symptom. Resection and Dacron graft interposition were performed without postoperative morbidity.     

腹主动脉假性动脉瘤的腔内修复治疗

目的：总结覆膜支架置入腔内修复术治疗腹主动脉假性动脉瘤的经验,探讨其腔内治疗的安全性及有效性。方法：2011年1月至2012年12月间,收治的9例腹主动脉假性动脉瘤患者,男性7例,女性2例,年龄43～78岁,平均（66．7±11．0）岁。术前均行影像学仔细评估,采用切开或直接穿刺的方式置人覆膜支架隔绝瘤体。9例共置入20枚覆膜支架（其中1例采用“开窗”支架,5例采用一体式分叉型支架,3例采用直筒型支架）。术后1,3,6及12个月均行CTA复查,观察有无内漏,瘤腔是否完全血栓化。结果：9例均成功地置入覆膜支架,技术成功率100％（9／9）。围手术期无死亡病例。随访1—23个月,1例术后1．5个月因感染复发转外科手术治疗,1例术后5个月死于呼吸衰竭,余患者瘤腔均完全血栓化。随访期间病死率11．1％（1／9）,并发症发生率22．2％（2／9）。结论：采用覆膜支架植入腔内修复术治疗腹主动脉假性动脉瘤近期疗效安全可靠,中远期疗效尚需进一步观察。     

Peptic ulcers and abdominal aortic aneurysms

Upper gastrointestinal endoscopy was performed in 106 of 204 Chinese patients with intact abdominal aortic aneurysms, ninety-seven for screening and nine for gastrointestinal bleeding or pain. Peptic disease was discovered in 38 patients: 12 duodenal ulcers, 12 gastric ulcers, four duodenal and gastric ulcers, three duodenitis, three gastritis and four previously operated for ulcers. The eight patients who bled before aneurysmectomy all had gastric ulcers; four required emergency operation and two died. Only two patients bled from duodenal ulcers, both after aneurysmectomy and one died. Excluding gastritis and duodenitis, peptic ulcer was found in 26.4% of patients with abdominal aortic aneurysms. Half of these ulcers were gastric ulcers and 50% of them bled before aneurysmectomy. Duodenal ulcers tend to remain asymptomatic before operation and two of 12 (16.7%) bled postoperatively. The risk of bleeding for ulcers associated with aneurysms was 10 of 28 (35.7%) ulcers. The result of this uncontrolled study suggests that routine endoscopic screening should be used in all patients with aortic aneurysms and early surgery should be offered for gastric ulcers.     

Familial occurrence of abdominal aortic aneurysm

BACKGROUND: A family history of abdominal aortic aneurysm has been reported to increase the risk for developing the disease. OBJECTIVE: To determine the risk for abdominal aortic aneurysm in first-degree relatives of patients with the disease. DESIGN: Cross-sectional ultrasonographic screening study. SETTING: University Central Hospital, Helsinki, Finland. PATIENTS: 238 of 325 living first-degree relatives of patients having surgery for abdominal aortic aneurysm (age > 50 years; 98 men and 110 women) and 281 controls (135 men and 149 women) without a family history of abdominal aortic aneurysm. MEASUREMENTS: Ultrasonography was used to measure aortic diameter in 101 male relatives and 140 female relatives (241 of the 325 persons at risk [74%]) and in 281 controls. RESULTS: Three siblings had already undergone surgery for abdominal aortic aneurysm. Eleven siblings (all brothers) (11 of 101 [10.9%]) had ultrasonographic evidence of abdominal aortic aneurysm (aortic diameter > 30 mm). In the control group, 2 men (1.5%) and 2 women (1.3%) had an aneurysm. Thirty siblings and no controls had dilatation of the abdominal aorta (aortic diameter, 20 to 29 mm). Neither the age nor the sex of the proband affected risk for developing abdominal aortic aneurysm among first-degree relatives. Family history increased the risk for an aneurysm by 4.33-fold (95% CI, 1.32-fold to 14.23-fold), male sex increased the risk by 12.21-fold (CI, 2.63-fold to 56.64-fold), and age (by decade) increased the risk by 1.93-fold (CI, 1.15-fold to 3.25-fold). CONCLUSION: Aging brothers of patients with known abdominal aortic aneurysm have the highest risk for developing the disease; the prevalence of the disease in siblings older than 60 years of age is 18%.     

Angiotensin II and abdominal aortic aneurysms

Abdominal aortic aneurysms (AAAs) have devastating effects on the morbidity and mortality of a large portion of the elderly population. Current therapeutic options for AAAs are limited to surgical approaches, because there are no proven pharmacologic treatments. Recently, there is evolving evidence that angiotensin II (Ang II) participates in the initiation and propagation of AAAs. Animal studies have consistently demonstrated the ability of Ang II to promote the formation of AAAs, although the mechanisms of this effect have not been defined. Further definition of the role of the renin-angiotensin system in AAA formation and progression will identify potential therapeutic strategies for treatment of this disease.