A ruptured abdominal aortic aneurism occurs when the thinned out wall of an abdominal aortic aneurysm gives way.
Rupture usually follows atherosclerosis or mycotic aneurism (aneurysm due to a fungal infection).
A ruptured abdominal aortic aneurysm could be sudden or may actually follow a long standing leak.
Risk factors for a Ruptured Abdominal Aortic Aneurysm
The following individuals who have an abdominal aortic aneurysm are more likely to have a rupture:
• Aneurysms with diameter of 5.5 – 5.9 cm have a 9 in a 100 chance of rupture within a year
• Aneurysms with diameter of 6.0 – 6.9cm have a 1 in 10 chance of rupture within a year
• Aneurysms with diameter greater than 6.9cm have 1 in 3 chances of rupture within a year
• Current smokers have a 7 fold risk of rupture than someone who has never smoked
• Ex-smoker with aneurysm have a 3 fold risk of rupture than someone who never smoked
• A male with aneurysm between the ages of 60 – 80. The risk of rupture decreases after this age
• A woman with aneurysm after the age of 80 years. It is rare for women to have a rupture before this age
Symptoms of Ruptured Abdominal Aortic Aneurysm
Symptoms of a ruptured abdominal aortic aneurism will include:
• Back pain
• Abdominal mass or swelling which may be pulsating
A 71 years old gentleman who is known to have hypertension, but controlled with medications developed sudden onset abdominal pain while on the table having breakfast.
The pain was very severe and radiates or spread to his back. Within minutes, he became sweaty, dizzy and collapsed by the dinning table.
His wife called an ambulance immediately, and was brought into the Emergency Room.
On arrival, he was cold and clammy, looked very pale.
His pulse rates were difficult to feel and his blood pressure were not recordable.
On his abdomen was this large egg shaped mass, visibly pulsating.
A diagnosis of ruptured abdominal aortic aneurism was made on clinical grounds.
He was taken straight to theatre.
Differential Diagnosis of Ruptured Abdominal Aortic Aneurism
The diagnosis of a ruptured abdominal aortic aneurism is often very clear. This is sometimes not the case, and one should bear in mind other conditions that could present like a ruptured abdominal aortic aneurism. These include:
Ruptured abdominal organs following trauma
Diagnosis of Ruptured Abdominal Aortic Aneurism
The diagnosis of ruptured abdominal aortic aneurism is often made from the history and examination.
Urgent bed side ultrasound scan could be one when one is not sure.
If the patient is stable, an abdominal X-ray or even a Ct-scan may help provide further proof.
Blood test done would include:
• Full or complete blood count (FBC or CBC)
• Clotting test
• Glucose level
• Blood grouping and cross match (10 – 30 units)
ECG (EKG) is also done to rule out a heart attack or other heart problems
Treatment of Ruptured Abdominal Aortic Aneurism
Dead is sure and swift without treatment of ruptured abdominal aortic aneurysm.
The first step in treatment is resuscitation, and then followed by operative procedure.
This is off course in those in which decision to operate has been taken.
Where a decision not to operate is reached, death is made to be as painless as possible through a tender loving care management with the use of morphine, anti sickness medication, keeping the patient warm and well rehydrated.
Such painful decision not to operate are often taken if it is thought that the patients quality of life would be very pool after surgery, or if there are so many other chronic conditions like previous heart attacks, lung diseases (Chronic Obstructive Airway Disease – COAD, chest infection, Lung cancer, e.t.c.), that will mean that death on the operating table is sure. It is thus a kind thing not to mutilate one certain to die.
Age is not a reason not to operate on someone with ruptured abdominal aortic aneurism (we have operated on a 91 yr old chap with ruptured abdominal aortic aneurysm, and he survived!).
While theatre is been prepared, the following are steps taken to resuscitate and prepare patients with ruptured AAA for surgery:
• Get two large bored cannulae (at least size 16G) venous access and
• Start giving fluids. Colloids and crystalloids can be given (2 litres of Hartman’s solution and gelofusin or isoplasma stat)
• Blood. 10 – 30 units of blood would be required
• For those not accepting blood transfusion, the use of plasma expanders like isoplasma, dextran and other heavy colloids have saved lives.
Blood loss is enormous following ruptured abdominal aortic aneurism. Decision not to accept blood transfusion should not be a reason to refuse someone with this condition an operation. Only recently, a 70 years old brought in with ruptured abdominal aortic aneurism had surgery without the need for blood transfusion. His pre-operative haemoglobin was 14.0g/dL, and post operative haemoglobin level was 12.0g/dL. This is the exception though, not the rule.
It only highlights the point that it may be worth giving a chance of surgery to those who would not accept blood transfusion
• Aim to maintain systolic blood pressure at about 80 – 90mmHg, but certainly not more than 100mmHg so as not to worsen bleed
• G-suit and MAST trousers
• Catheterise and aim for urine volume of 0.5mg / Kg / hour
• Some give prophylactic antibiotics
• Get the most senior and or experienced vascular surgeon and anaesthetist
• Keep patient warm with a warm touch blanket
This is a very massive and blood major surgery. An incision is made from top to bottom of the abdomen, and the abdomen opened up. The aorta is identified and clamped above the point of rupture.
The arteries to the kidneys, which are branches from the aorta are identified and secured.
Other structures cleared off the way and a graft, which is an artificial artery tube, is placed in where the aorta has ruptured and sewn in place, bridging the defect.
Any possible extension of an aneurysm is identified and repaired.
The abdomen is covered, with large drains coming out from the sides.
If the bowels were found to be much distended during surgery, a large towel may be left in and the abdomen not covered for 24 to 48 hours to allow the swollen (oedematous) guts loose water and less swollen. This is to prevent a very dangerous complication of abdominal aortic aneurism repair called abdominal compartment syndrome.
This is a very very high risk surgery. Up to 9 out of ten who go in for this operation, depending on a host of factors, may not survive.
It is however a surgery worth trying for the few who may survive.
After the surgery, patient is often taken to a high dependency unit or even an intensive care unit for close monitoring or organ support.
Complications of a ruptured abdominal aortic aneurism repair include:
• Heavy blood loss
• Compartment syndrome
• Aorto-duodenal fistula
• Graft infection
• Wound breakdown
• Lung collapse
• Kidney failure
We shall discuss these complications in greater details at the section on Complications of Abdominal Aortic Aneurysm Repair
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