aaa aortic aneurysm.pdf
TRANSCRIPT
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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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