A 71-year-old male, referred by his GP for investigation and management of 1 month history of intermittent back pain. background history : Hypertension, hypercholesterolemia and coronary bypass 20 years ago[i2] | |
2 - History of Presenting Complaint: | |
S- lumbosacral region R-radiates to posterior left leg C-dull achy sensation but was sharp at times O-since 4 weeks ago, no previous similar episodes P-intermittent D- varies in duration. Prior to his presentation, the patient had been in bed for a period of two weeks following a diagnosis of lumbosacral sprain and prescription of bed rest and heat application by his GP. | |
3 - Past Medical History: | |
1. MI- 20 yrs 2. HTN – 20 yrs 3. Hypercholesterolaemia- 20 yrs | |
4 - Past Surgical History: | |
1. Appendicectomy – 15 years old 2. Coronary bypass- 20 years ago | |
5 – Medications: | |
1. Atorvastatin 10mg 2. Aspirin 75 mg 3. Atenolol 100mg, 4. chlortalidone 25mg 1 tabs OD PO 5. Lansoprazole 30mg OD PO 6. Tramadol | |
6 - Allergies: | |
No known drugs or food allergies. | |
7 – Family History: | |
1. Father- died from heart attack at 60 yearsold 2. Mother-died of old age 88 | |
8 – Social History: | |
1. Ex-smoker, stop smoking after having MI, smokes 40 ciggarate/ day for 40 years 2. Drink alcohol occasionally = 4 units/week 3. Pensioner, life with his wife in a single storey house. | |
9- System review – unremarkable | |
10- physical examination | |
On general inspection: the patient sitting comfortably at the edge of the bed. Not in any respiratory distress. Good color and well nourished. Pain free Vital signs: Elevated blood pressure : 140/85 respiratory rate 16 breaths/min pulse: 68 beats/min regular and of normal volume and character Temperature: 37ºC O2 sat ; 98% RA Examination of lower back: LOOK No scars or deformities, FEEL No tenderness/warmth on palpation MOVE: a 50% limitation in lumbar flexion and extension at L4-S1reigon. All other ROM were normal Lower limb neurological examination was all normal. -normal gait, -no muscle wasting, fasciculation, -power 5/5 bilaterally - reflex- normal -coordination, proprioception, sensation were intact Abdominal examination- Abdomen is not distended, 5 cm well healed scar at right lumbar region Soft and non-tender, no guarding, no rigidity Positive finding on abdominal palpation- expansile and pulsative mass predominantly above the umbilicus. No bruit on auscultation, bowel sound was normal. Other GI signs were un remarkable. CVS- sternotomy scar was present. 1st and 2nd sound were present , with pansystolic murmur, loudest at mitral area and radiate to the axilla, 3/5 in intensity- which is consistent to mitral regurgitation. Peripheral pulses were all present and normal. Respi- normal. Air entry is equal bilaterally, no wheeze of crepitation | |
Summary- this is 77 years old man, presented with one month history of lower back pain with multiple risk factors of cardiovascular disease includes, htn, hypercholesterolemia, previous MI, positive family history, and history of smoking. Positive finding on examination include hypertension, limited range on movement at L4-S1, expansile and pulsatile abdominal mass and pansystolic murmur. Differential diagnosis for the presentation includes : 1-AAA 2-lumbar spinal stenosis 3-lumbar spinal sprain 4-malignancy 5- degenerative ( OA) | |
Investigation | |
FBC, ESR,CRP, U+E normal Abdominal US : 5 .5 cm AAA with intramural thrombus XRAY of spine was normal, apart from calcification on Abdominal aorta wall CT- 5.5cm A.P x 5 cm transversely, infrarenal abdominal aortic aneurysm, with thrombus. No evidence on leak He is now scheduled for an EVAR[i4] | |
Pre-op work up | |
Blood : crossmatch, coagulation, LFT Pre operative assessment: Ø Cardiac – unstable angina, Recent MI, CCF § ECG, Stress Test, Echo, Coronary Angiogram § 70% of patients with an AAA will have significant Coronary Artery Disease Ø Pulmonary – Respiratory reserve § PFT’s, CXR, ABG Ø Renal – Cr Imaging q 3D reconstruction of spiral CT images q Size/extent of aneurysm - abdominal/thoraco-abdominal q Relation to renal arteries/involvement of iliac vessels | |
Discussion | |
Complication of EVAR : Bleeding q graft site q Venous q DIC Respiratory q Atelectasis q Pneumonia q ARDS q Pulmonary oedema q Pulmonary Embolism Cardiac q CCF q Arrhythmias q Ischaemia/MI- in 20% q Myocardial Depression Gastro-Intestinal Tract q Mesenteric ischaemia q Paralytic ileus q Malnutrition Renal q UTI q Renal failure- high dose nephrotoxic contrast Lower Limbs q Acute limb ischaemia q Deep venous thrombosis Wound Complications q Infection q Dehiscence q Incisional hernia Spinal Cord q Paraplegia Infected graft q Pseudo-aneurysm formation q Aorto enteric fistula Impotence Ischemia Reperfusion Syndrome | |
Follow up/ Post-Discharge plan | |
30 day mortality 1.7% EVAR vs 4.7% Open 15% EVAR Further Intervention These patients require frequent and prolonged clinical and radiological follow-up, not only to monitor for endoleak, but also because there is no information on the long-term outcome of this type of repair. |
[i1]PRESENTING COMP:
n Asymptomatic - 75%
n Incidental finding
q Routine examination
q Ultrasound Sound scanning/Plain Film Abdomen for other reason
q Patient notices pulsatile mass
n Symptomatic
q Distal Embolisation
(blue toe syndrome)
q Leak
(abdominal/back /flank pain)
q Rupture
(hypovolaemic shock, sudden epigastric/back pain)
q Fistulation – “Rare”
(aorto-caval/aorto-enteric)
[i2]Risk Factors :
q Smoking
q Hyperlipidaemia
q Hypertension
q Peripheral vascular disease
q Marfan Syndrome, Ehlers-Danlos syndrome
q Prevalence of AAA in siblings of patients with known aneurysm is approximately 4 times greater than in individuals with no family history
[i3]Rule out Spinal nerve compression, degenerative disease, rheumatoid, malignancy, infection, trauma
n [i4]Indications for Surgery:
q Rupture
q Symptomatic - back/flank/abdominal pain, embolisation
q Rapid increase in size >0.5 cm/year
q Asymptomatic ≥ 5.5 cm – exact lower limit controversial
q Aorto-caval/Aorto-enteric fistula