Case Study: Chapter 07

Chapter 7, Abdominal Aortic Aneurysms: Diagnosis and Catheter-Based Approaches

ELIZABETH L. DETSCHELT, MD; MANISH MEHTA, MD, MPH

CASE STUDY:

A 76-year-old man with a history of smoking, hypertension, and coronary artery disease status requests evaluation for a possible AAA. He recently received a call from his brother, who at the age of 78 years has been diagnosed with an AAA that needs repair. The patient does not complain of abdominal or back pain. Both of his parents died in their 80s from unknown cause. He has 3 brothers and 3 sisters, ranging from 70 to 82 years.

On physical examination, the pulse is 84 and blood pressure is 178/88. Carotid pulses are normal; there are no carotid bruits. The heartbeat is regular and without murmurs, rubs, or gallops. Lungs are clear bilaterally. He is moderately obese, with no pulsatile AAA. He has femoral and pedal pulses bilaterally, as well as prominent popliteal pulses bilaterally. There are no signs of atheroemboli.

Case Study: Chapter 7

* 1.) Which of the following is most appropriate?
2.) Duplex ultrasound reveals a 6-cm infrarenal AAA. A CT scan confirms a 6-cm infrarenal AAA that appears anatomically suitable for EVAR (Case Study Figure 1A).

Lower extremity duplex ultrasound (Case Study Figure 1B) indicates ectatic femoral and popliteal arteries that measure 1.5 cm in maximum diameter. As you begin to discuss treatment option, the patient asks why the aneurysm needs to be fixed at all. What is the annual risk of rupture for a 6-cm AAA?

* 3.) You discuss the pros and cons of EVAR and open repair. The patient asks how dangerous the procedure is. What is the perioperative mortality of EVAR and of open repair?
* 4.) Appropriate medical and cardiac evaluation is performed, and the patient undergoes successful EVAR. In addition to routine clinical evaluation, what is the most appropriate follow-up?
* 5.) Two years have passed since the patient underwent EVAR. He is currently undergoing routine yearly CTA. The CTA one year ago showed that the AAA sac decreased in size from 6 cm to 4.5 cm, without any endoleak.

The most recent CTA indicates the AAA size to be 5.8 cm and the presence of a type II endoleak. Which of the following is the most appropriate next step?