eMedicine Specialties > Emergency Medicine > Cardiovascular

Aneurysm, Abdominal: Follow-up

Author: Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Contributor Information and Disclosures

Updated: Sep 8, 2009

Follow-up

Further Inpatient Care

  • Patients require admission when they are unstable or symptomatic, when they have significant comorbid conditions, or when the diagnosis is uncertain.
  • Elderly patients or those with preexisting conditions (eg, emphysema, hypertension, congestive heart failure, coronary artery disease, cerebrovascular disease, renal insufficiency) may require stabilization prior to elective surgery.
  • Asymptomatic patients with inflammatory abdominal aortic aneurysm (AAA) or AAA in association with distal emboli, pain, or bowel obstruction require emergent repair regardless of aneurysm size.
  • The two primary methods of AAA repair are open and endovascular.
  • Open AAA repair requires direct access to the aorta through an abdominal incision. The open repair method is well established as definitive, having been in used for over 50 years.
  • Endovascular repair first became practical in the 1990s and is now an established alternative to open repair. Endovascular repair of an AAA involves gaining access to the lumen of the abdominal aorta, usually via small incisions over the femoral vessels. An endograft, typically a cloth graft with a stent exoskeleton, is placed within the lumen of the AAA extending distally into the iliac arteries. The graft serves to contain aortic flow and decrease the pressure on the aortic wall, leading to a reduction in AAA size over time and a decrease in the risk of aortic rupture.

Further Outpatient Care

  • Close follow-up is required after endovascular repair with serial CT scans performed at 1, 6, and 12 months, and then yearly to ensure that the graft is effective.
  • Patients with incidental abdominal aortic aneurysm (AAA) that is less than 3 cm require no further follow-up. If the AAA is 3-4 cm, annual ultrasound imaging should be used to monitor for further dilatation. AAAs 4-4.5 cm should be evaluated by ultrasound every 6 months, and patients with AAAs greater that 4.5 cm in diameter should be referred to a vascular surgeon.

Transfer

  • Surgical repair should be performed as expediently as possible by an experienced surgeon.
  • Transfer of an unstable patient with AAA should only occur if the sending facility is incapable of operative care. Personnel skilled at resuscitation should accompany the transfer.
  • Consideration can be given to transfer stable asymptomatic patients after appropriate imaging studies have excluded rupture, expansion, or leak.

Prognosis

  • The prognosis is guarded in patients who suffer rupture prehospital. More than 50% do not survive to the ED; of those who do, survival rate drops by about 1% per minute. However, survival rate is good in the subset of patients who are not in severe shock and who receive timely, expert surgical intervention.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Patients who complain of back, flank, groin, or abdominal pain but have stable vital signs and do not appear ill present diagnostic challenges. They may be sent home or kept for extended periods in the ED while waiting for diagnostic testing for suspected ureterolithiasis or other benign abdominal conditions. If AAA ruptures and shock ensues, morbidity and mortality increase dramatically. Emergency physicians have been held liable for failure to diagnose AAA and obtain appropriate consultation in these situations. A high index of suspicion is necessary to avoid this medical-legal pitfall.
 


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References
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References

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Further Reading

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Keywords

abdominal aneurysm, abdominal aortic aneurysm, AAA, mycotic aneurysm, abscess formation, atherosclerosis, smoking, chronic obstructive pulmonary disease, COPD, hypertension, syncope, shock, cyanosis, sudden cardiovascular collapse, peripheral atherosclerotic vascular disease, Marfan syndrome, Ehlers-Danlos syndrome, collagen vascular diseases, mycotic aneurysm, claudication, pulsatile abdominal mass, abdominal bruit, aortic rupture

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Contributor Information and Disclosures

Author

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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