AAA Aortic Aneurysm.pdf

8/9/2019 AAA Aortic Aneurysm.pdf

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fatal testicular painmichael c. david


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outline

case review

tutorial 1 (medical students)

summary of literature

tutorial 2 (SHOs & students)

case reflection


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case review

medications: aspirin, warfarin (INR 1.9)

simvastatin

lisinopril

thyroxine

allergies: nil known

examination: CVS uncompromised (stable obs)

no hernia, no testicular swelling

mild rt testicular pain

soft abdomen, 7 cm expansile mass

full complement of peripheral pulses


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case review

urinalysis: unremarkable

blood tests: Hb 147, WCC 12.2, Plt 197

normal renal & liver function

CRP


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case review

straight to theatre (EVAR) – no heparin

dropped b.p. returned to theatre

angiogram – no type 1 leak

distended abdomen – rupture (type 2 leak)

DIC

prognosis grim

RIP


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tutorial 1

abdominal aortic aneurysm


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la place’s law

risks

atherosclerosis

hypertension

age > 60, male

smoking

COPD (chronic cough)

collagen disorders

trauma

internal

pressure

(P)

surface tension

(T)

d i a m e t e r

( r / 2 )

2

r P T


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symptoms

asymptomatic

vague abdominal pain

low back painrenal impairment (renal artery)

loin pain and haematuria (RPF)

leg ischaemiapulsatile mass

rupture


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complications

infection

ischaemia (kidneys, mesentery)

distal embolismmass effect (ureters, RPF)

rupture

hypovolaemic shockperitonism (useful)

death


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management

conservative

risk factor reduction

surveillance

symptom control

medical – statins, antihypertensives

interventional

open surgery (assess comorbidities)

EVAR (beware embolism & endoleaks)


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endoleaks

1. at seals

2. retrograde vessels

3. material failure,disconnection

4. porosity

5. unknown


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literature review

unusual symptoms


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unusual symptoms

bilateral or unilateral testicular pain

six cases found in Pub Med

isolated pain

stable, leaking and rupture AAA involved

embryonic development of testes

testicular arteries are paired visceral branches

arise from aorta at L2

run in inguinal canal to enter spermatic cord


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unusual symptoms

coeliac trunk

superior mesenteric artery

right renal artery

right testicular artery

inferior mesenteric artery

left common iliac artery


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unusual symptoms

buttock pain Emerg Med J. 2005 Jun;22(6):453-4

paraplegia Eur J Vasc Endovasc Surg. 2002 May;23(5):465-6

anterior spinal artery compromise

low origin of giant radicular artery of Adamkiewicz, 11%

main contribution to the inferior 2/3 anterior spinal artery

paraparesis Paraplegia. 1995 Aug;33(8):480-1RA & lumbago developed b/l leg weakness & hesitancy


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unusual symptoms

crural neuropathy Ann Vasc Surg. 2001 May;15(3):405-11

obstructive jaundice Surg Today. 2001;31(4):331-2

contained rupture with haematoma compressing CBD

unexplained back pain Can J Surg. 1994 Feb;37(1):23-8“contained rupture of an aortic aneurysm should be

considered in older patients with unexplained back pain,

and the possibility of this condition should not be

ignored when there is a history of arthritic back pain or a

radiograph suggestive of degenerative disease.”


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unusual symptoms

inguinal or retroperitoneal massEur J Vasc Surg. 1991 Dec;5(6):695-6

J Vasc Surg. 1986 Oct;4(4):384-9 Acta Chir Belg. 1986 Jul-Aug;86(4):245-7

right haemothorax Can J Surg. 1986 Mar;29(2):133-4exsanguination through an erosion in the crural fibres of

the right diaphragm

left renal vein fistula Ann Surg. 1976 Jul;184(1):31-4hematuria, proteinuria, and azotaemia

imaging often shows a large non-functional left kidney


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tutorial 2

disseminated intravascular

coagulation


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d i c

unregulated thrombin explosion

release of free thrombin into the circulation

widespread microvascular thrombosis

tissue ischaemia, organ damage

attempt to maintain vessel patency plasmin

dic = thrombotic and haemorrhagic manifestations


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chronic d i c

same process, less explosive

chronic inflammatory conditions

(malignancy, infection, dead foetus, AAA)

time for compensatory mechanisms

recurrent VTE (Trousseau’s syndrome)

prevented by heparin not warfarin


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case reflection


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AAA causes chronic inflammation, and

cytokine expression Eur J Cardiothorac Surg 2003;23:1034-39

in 33% of patients with AAA chronic DIC

can be identified Hamostaseologie. 2004 Aug;24(3):162-6

guidewire introduction can dislodge muralthrombus shower embolus triggered DIC

and death after EVAR Radiographics. 2000;20(5):1263-1278


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AAA Aortic Aneurysm.pdf