Weighing risks in abdominal aortic aneurysm. Best repaired in an elective, not an emergency, procedure

Abdominal aortic aneurysm in a patient with low back pain

STUDY DESIGN

Resident's case problem.

BACKGROUND

The purpose of this report was to describe (1) the clinical reasoning that led a clinician to identify an abdominal aortic aneurysm (AAA) in a patient with low back pain requiring immediate medical referral, and (2) an evidence-based approach to clinical evaluation of patients with suspected AAA.

DIAGNOSIS

The patient was unable to identify a specific mechanism of injury for his low back pain, lacked aggravating/easing factors for his symptoms, and complained of night pain and an inability to ease his symptoms with position changes. While the patient's symptoms remained unchanged during physical examination of the lumbar spine and hip, abdominal palpation revealed a strong, nontender pulsation over the midline of the upper and lower abdominal quadrants. Due to concern for an AAA, the patient was immediately referred to his physician. Subsequent computed tomography imaging revealed a prominent AAA, which measured up to 5.5 cm in greatest dimension and extended from below the renal arteries to the bifurcation of the iliac arteries. The patient initially deferred surgical intervention but eventually consented 6 months later, after repeat computed tomography imaging revealed that the AAA had progressed to 6.7 cm in greatest dimension.

DISCUSSION

It is essential for physical therapists to be familiar with a diagnostic pathway to help identify AAA in patients presenting with apparent musculoskeletal complaints. Knowledge of the risk factors for AAA, understanding how to screen for nonmusculoskeletal symptoms, and a basic competence in abdominal palpation and how to interpret findings will help with the clinician's clinical decision making.

LEVEL OF EVIDENCE

Differential diagnosis, level 4. J Orthop Sports Phys Ther 2014;44(7):500-507. Epub 25 April 2014. doi:10.2519/jospt.2014.4935.

Prevalence of Abdominal Wall Hernia in Participants With Abdominal Aortic Aneurysm Versus Peripheral Arterial Disease—A Population-Based Study

Small studies suggest an association between abdominal aortic aneurysms (AAAs) and hernias, possibly related to connective tissue weakness. We evaluated the association between AAA and abdominal wall hernia (AWH), using peripheral arterial disease (PAD) patients as controls, in Olmsted County, Minnesota. In a retrospective cohort study we queried the electronic medical records for the diagnosis of AAA. The resulting data were then queried for prevalence of AWH. The same set of queries was repeated for PAD. Occurrence of AWH in the 2 groups was compared using the chi-square test. Of the 187 151 patient records queried, 939 had AAA and 3465 had PAD. Abdominal wall hernia occurred in 157 (16.7%) patients with AAA and in 343 (9.9%) patients with PAD. Abdominal wall hernia was 1.7 times more prevalent in those with AAA versus PAD ( P < .0001). A history of hernia may prompt screening for AAA in some patients.

Prevalence of abdominal aortic aneurysms in over 65-year-old men with inguinal hernias

INTRODUCTION

The aim of this study was to determine the prevalence of abdominal aortic aneurysms (AAAs) in over 65-year-old men who have inguinal hernias and discuss if pre-operative selective screening of this population is appropriate.

PATIENTS AND METHODS

A prospective study on 70 consecutive male patients with an age range of 65-88 years (mean, 74 years) who were referred to a single vascular consultant's out-patient clinic with an inguinal hernia were screened for the presence of an AAA with an ultrasound scan before hernia repair over a period of 3 years.

RESULTS

Two patients were found to have an AAA measuring 3.8 cm and 6.0 cm giving an AAA prevalence of 3% (exact 95% confidence interval = 0-10%).

CONCLUSIONS

This study does not demonstrate an increased AAA prevalence in over 65-year-old male patients with inguinal hernias, scanned pre-operatively when compared to screening programmes. Selective screening of this cohort cannot be justified on this evidence.

Differential diagnosis of a patient referred to physical therapy with low back pain: abdominal aortic aneurysm

STUDY DESIGN

Resident's case problem.

BACKGROUND

A 38-year-old man with a history of chronic episodic low back pain (LBP) was referred to physical therapy by his physician.

DIAGNOSIS

Concerns ascertained from the patient's history included an insidious onset of unrelenting, deep, boring pain that was constant, irrespective of movements or posture changes, or time of day. In addition, the patient reported night pain and the inability to find relief in recumbent positions. The primary warning signs associated with the physical examination were unremarkable examination of the lumbar spine, pelvis, and hip regions (symptoms not altered and minimal impairments detected), and a strong nontender, palpable pulse noted over the left lateral lumbar region, with the patient prone, and over the midline and left upper/lower abdominal quadrants, with the patient supine. Suspicion of the presence of an abdominal aortic aneurysm led the therapist to immediately refer the patient to an allopathic physician. The subsequent abdominal ultrasound and computed tomography scanning revealed a 10-cm-diameter abdominal aortic aneurysm. The patient was immediately hospitalized and underwent surgical repair within two days.

DISCUSSION

LBP is the most frequent condition for patients seeking care from physical therapists in outpatient settings. The challenge for clinicians is to recognize patients in whom LBP may be related to underlying pathological conditions. A prompt referral of patients presenting with suspicious findings to the appropriate physician may lead to a more timely diagnosis, with the goal of minimizing or preventing morbidity and mortality.

The importance of differentiating between elective and emergency postoperative critical care patients

PURPOSE

The purpose of the study is to demonstrate the importance of separately analyzing data on elective and emergency surgery patients admitted postoperatively to intensive and intermediate care units.

MATERIALS AND METHODS

A prospective observational study was performed in a tertiary care university hospital to assess the demographic and clinical differences between emergency and elective surgical patients (>14 years old). Group 1 included patients transferred to a floor bed or the ambulatory surgery unit for discharge home after a short stay (<12 hours) in the postanesthesia care unit. Group 2 patients were admitted to the cardiothoracic intensive care unit (ICU), neurosurgical ICU, general ICU, or for an extended intermediate care postanesthesia care unit stay (>12 hours).

RESULTS

In groups 1 (n = 1059), there were significant differences between the elective and emergency patients. Emergency, as compared with elective group 2 (n= 1883) patients, experienced more severe preexisting illnesses (ie, had higher American Society of Anesthesiology classifications), underwent different and shorter operations, required prolonged postoperative mechanical ventilation, required longer ICU stays, and had higher mortality.

CONCLUSIONS

Substantial differences between elective and emergency surgery patients have important implications when conducting and reporting research on the nature, extent, and outcome of postoperative ICU care.

The influence of aortic cuffs and iliac limb extensions on the outcome of endovascular abdominal aortic aneurysm repair

BACKGROUND

In a proportion of patients with an endovascular abdominal aortic aneurysm repair (EVAR), aortic cuffs or iliac graft limb extensions are required to enhance sealing or to fix the position of the device. This requirement arises when these goals are not primarily obtained with the basic stent-graft configuration. The aim of this study was to assess the influence of the use of endograft extensions during the primary EVAR procedure on the short- and long-term outcome.

METHODS

The study was based on the data of the EUROSTAR registry. Patient and anatomic characteristics, data regarding the procedure, postoperative complications, and the mortality of patients undergoing EVAR were retrieved from the database. Patients were divided into three groups: (1) no extensions, (2) proximal aortic cuffs, and (3) iliac limb extensions. Logistic regression and Cox proportional hazards models were used to compare significant influences of the use of cuffs or extensions on different outcomes relative to control patients, adjusted for patient and anatomic factors.

RESULTS

The overall cohort comprised 6668 patients: 4932 (74.0%) without extensions, 259 (3.9%) with an aortic cuff, and 1477 (22.2%) with an iliac endograft extension. Both the 30-day (2.3%-3.9%) and the all-cause mortality rates (23%-27% at 4 years) were similar in the three study groups. The use of proximal cuffs or iliac extensions did not have an effect on the incidence of endoleaks of any type (24%-32% at 4 years). The incidences of device kinking (P = .0344) and secondary transfemoral interventions (P = .0053) during follow-up were increased in patients in whom iliac limb extensions were used. In patients with aortic cuffs, no significant associations with altered outcome were observed.

CONCLUSIONS

The use of iliac graft limb extensions at EVAR was associated with a higher incidence of kinking and secondary transfemoral interventions, whereas proximal aortic cuffs did not influence outcome.