General Practitioners - AAA

Aortic and iliac aneurysms

Majority of patients with aorta and iliac aneurysms are in the 7th and 8th decade of life. There is familial inheritance especially in males. Current recommendation is any male with family history of AAA be screen with ultrasound every decade from 50 years of age. Aneurysms are usually found incidentally and are asymptomatic. Symptomatic aneurysms should be sent urgently to emergency department for assessment regardless of size.

Aneurysm usual growth rate is 10% per year. So we would expect a 4.0cm AAA to grow to 4.4cm in one year. Though any size aneurysm can rupture, it uncommon (1-2%) when size is less than x2 original size of the artery. As repair, both endoluminal and open repair have significant risks and complications, generally repair is reserved until the artery is > x2.5 expected size.

Options for repair are endoluminal and open repair. Patients are initially assessed with CT angiogram for suitability of endoluminal repair. Certain anatomical configuration is needed for the endoluminal repair to be successful. Endoluminal repair has re-intervention rates of approximately 15%, but much greater if anatomy is not suitable. When the stent graft fails to completely exclude flow in the aneurysm sac it is referred as endoleak. Majority of endoleaks can safely monitored long term but some require re-intervention.

If the anatomical morphology is unsuitable for endoluminal repair then open repair is contemplated. This is a major assault and requires enough cardiac, respiratory and renal function. Mortality from open repair is generally 5% but morbidity is much higher. Its major advantage is that patients do not require ongoing follow-up unless they have other aneurysms.

Increasingly with aging population we are encountering older patients with significant cardiac, respiratory and renal disease. If they are not anatomically suitable for endoluminal repair they pose difficult decision making process on whether to proceed with surgery.