eMedicine Specialties > Radiology > Vascular/Interventional

Abdominal Aortic Aneurysm, Rupture: Follow-up

Author: Walter A Tan, MD, MS, Assistant Professor of Medicine (Cardiology) and Radiology, Director of Vascular Medicine Program, Departments of Medicine and Radiology, Division of Cardiology, University of North Carolina at Chapel Hill
Coauthor(s): Michel S Makaroun, MD, Professor of Surgery, Chief, Division of Vascular Surgery, University of Pittsburgh School of Medicine; Program Director, Medical Director of Peripheral Vascular Laboratory, University of Pittsburgh Medical Center
Contributor Information and Disclosures

Updated: Mar 23, 2007

Intervention

In patients with AAA, initiate aggressive secondary prevention, including smoking cessation, dietary changes, and exercise. In addition, hypertension, hypercholesterolemia, and diabetes should be controlled.

AAA rupture, symptomatic expansion, or sentinel leak is a surgical emergency.50 In the unstable patient, initial surgical proximal aortic control with the avoidance of perturbation of any tamponade effect provided by extra-aortic structures or hematoma is critical.

Large supplies of blood and blood products, including platelets and fresh-frozen plasma should be readily available.32 The availability of intraoperative autotransfusion can diminish this need.

Stent grafting with the option of proximal balloon occlusion for control of bleeding is an experimental approach that may prove to be an alternative in selected patients.51

Medicolegal Pitfalls

  • The failure to diagnose a ruptured AAA is a pitfall that can occur in as many as 30-64% of patients.24 Marston catalogued the initial erroneous diagnosis in 46 of 152 retrospectively reviewed cases of ruptured AAA as shown in Table 7. Table 7. Misdiagnosis of AAA

    Open table in new window

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    Table
    Initial DiagnosisMisdiagnosed Cases, %Average Delay, h
    Renal colic2415
    Diverticulitis1379
    GI hemorrhage1317
    Acute MI8.713
    Back pain8.718
    Motor vehicle accident6.51.5
    Sepsis6.526
    Other GI problem6.54
    Other/no diagnosis1318
    Initial DiagnosisMisdiagnosed Cases, %Average Delay, h
    Renal colic2415
    Diverticulitis1379
    GI hemorrhage1317
    Acute MI8.713
    Back pain8.718
    Motor vehicle accident6.51.5
    Sepsis6.526
    Other GI problem6.54
    Other/no diagnosis1318
  • In one study, the mean delay to correctly make the diagnosis of ruptured AAA was 24.4 hours.52 Of note, a high degree of suspicion as well as careful attention to the abdominal examination may help minimize missing this diagnosis. In patients with a misdiagnosis, the vascular specialist was able to detect a pulsatile mass in 71%, compared with only 25% during the initial examination.52
  • In an analysis published in 1984, Hiatt found the following determinants of failure in the treatment of ruptured AAA:
    • Failure to perform elective aneurysmectomy in patients with known AAA
    • Initial misdiagnosis leading to delayed surgery
    • Undue delays in induction of anesthesia
    • Intraoperative technical errors, most commonly venous injuries (eg, renal, iliac, or lumbar vein hemorrhage, which can be difficult to control)

Special Concerns

  • Factors that portend an 80% or higher mortality rate include the following32,24 :
    • Patient aged 80 years or older
    • Shock presentation with free intraperitoneal rupture (in contrast to a mortality rate of approximately 20% in stable patients with a small contained rupture)
    • Persistent preoperative hypotension despite aggressive fluid and blood replacement
    • Preoperative cardiac arrest
    • Admission hematocrit level less than 25%
  • More results of recent series from select centers indicate possible improvements in surgical survival, and investigators advocate a continued aggressive approach for these patient subgroups.44
  • Because the average age of patients with AAA is high, comorbidities requiring unrelated surgeries are not uncommon in patients being followed up for AAA.32 Findings from several small series suggest an elevated risk of rupture after other surgical procedures.
    • The observed rate of rupture in association with open-heart surgery is 0-14%.35,53,54
    • Of the 13 patients who underwent open biliary procedures in the series by Fry and Fry, 1 patient had a thoracoabdominal aneurysm that ruptured 8 days after cholecystectomy.55 Conversely, an estimated 5% of patients with AAA also have gallstones and are considered at risk for cholecystitis after aneurysmectomy.
    • The observed prevalence of colon cancer is approximately 2% in the population with AAA. Nora and coworkers noted 3 (11%) AAA ruptures in 27 patients; all occurred within 3 days of surgery for intra-abdominal malignancy.56
    • Coexistent disease claims as many lives over time as do ruptures in patients with AAA. Therefore, preventive therapy to reduce the risk of atherosclerosis and its sequelae is mandated.
    • Special attention should be paid to the detection of inflammatory aneurysms because of the associated higher operative morbidity and mortality rates. Patients with these types of aneurysms account for 3-10% of those with AAAs, but as many as half of their aneurysms may go unrecognized before surgery. Abdominal or back pain is common, and significant weight loss is observed in as many as 25% (Pennell, 1985). The inflammatory process can also cause adhesions, ureteric obstruction with secondary hydronephrosis or pyelonephritis; renal failure; and, rarely, duodenal obstruction.
  • Acknowledgments: The authors would like to thank the staff of the Hopwood Library at UPMC Shadyside and Christopher Tan for their support and assistance.
 


More on Abdominal Aortic Aneurysm, Rupture

Overview: Abdominal Aortic Aneurysm, Rupture
Imaging: Abdominal Aortic Aneurysm, Rupture
Follow-up: Abdominal Aortic Aneurysm, Rupture
Multimedia: Abdominal Aortic Aneurysm, Rupture
References
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References

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Further Reading

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Keywords

AAA, perforated aneurysm, leaking aneurysm, pararenal aneurysm, aortic aneurysm, thoracoabdominal aneurysm, anastomotic aneurysm

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Contributor Information and Disclosures

Author

Walter A Tan, MD, MS, Assistant Professor of Medicine (Cardiology) and Radiology, Director of Vascular Medicine Program, Departments of Medicine and Radiology, Division of Cardiology, University of North Carolina at Chapel Hill
Walter A Tan, MD, MS is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Nothing to disclose.

Coauthor(s)

Michel S Makaroun, MD, Professor of Surgery, Chief, Division of Vascular Surgery, University of Pittsburgh School of Medicine; Program Director, Medical Director of Peripheral Vascular Laboratory, University of Pittsburgh Medical Center
Michel S Makaroun, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Association of VA Surgeons, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Eric P Weinberg, MD, Associate Professor, Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital
Eric P Weinberg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Spencer B Gay, MD, Professor of Radiology, Director of Body Computed Tomography, Department of Radiology, University of Virginia Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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