Young patient care of abdominal aortic aneurysm repair

Mercy1, Merin2, Harani3

1Non Critical Ward In charge, Kauvery Heart city, Trichy, Tamil Nadu

2,3Non Critical Ward Staff Nurse, Kauvery Heart city, Trichy, Tamil Nadu

Abstract

Abdominal aortic aneurysm is typically until rupture which carries 80% mortality. One time ultrasound screening in men aged >65 years significantly reduces (AAA) related mortality rupture and emergency surgeries over 13 – 15 years.  While screening shows clear benefits, potential psychosocial harms should also be weighted.

Definition

Abdominal aortic aneurysm is a localized enlargement of the abdominal aorta such that the diameter is greater than 3cm or more than 50% larger than normal.  It is most commonly in men.

Causes & risk factors

Degenerative most common atherosclerosis:

            Chronic inflammation, lipid deposition and plaque formation, weaken the vessel wall.

Age related degeneration

Elastin and collagen in the aortic break down over time.

Genetic & Connective tissue Disorders:

Marfan syndrome

Defective fibrillin – weakened connective tissue.

Ehlers – Danlos Syndrome

Collagen synthesis defect

Loeys– Dietz Syndrome

Family history of AAA strong hereditary component

Infectious Causes (Mycotic Aneurysm)

Infection of the aortic wall.

Common pathogen

salmonella, Staphylococcus Aureus, Streptococcus, Mycobacterium tuberculosis, Brucella.  Usually occurs after bacteremia or septic emboli lodge in the aortic wall.

Inflammatory causes

Conditions like Vasculitis (Takayasu arteritis giant cell arteritis, poly-arteritis nodosa).

Idiopathic inflammatory aneurysm:

Marked by dense periaortic fibrosis and inflammation.

Traumatic or Iatrogenic

Blunt abdominal trauma or penetrating injuries. Iatrogenic injury from surgery end-vascular procedures or radiation.

Risk Factors

  • Male Sex
  • Age > 65years
  • Smoking
  • Hypertension
  • Atherosclerotic disease
  • Hyper-lipidemia
  • Positive family history

Pathophysiology

Signs and symptoms:

  • More people with AAA don’t have symptoms until the aneurysm is close to rupturing.
  • Steady deep pain in your lower back or belly.
  • A pulsing sensation in your belly that feels like a heartbeat.
  • A ruptured AAA is a medical emergency symptom that begins suddenly including
    • Severe pain in your belly lowers back or legs.
    • Shortness of breath.
    • Fast heartbeat.
    • Low blood pressure.
    • Dizziness or fainting.
    • Nausea or vomiting.
    • Clammy, sweaty skin.

Grey turner’s Sign

Flank ecchymosed from retroperitoneal bleed.

Cullen’s Sign

  • Periumbilical ecchymosis.
  • Collapse or cardiac arrest if rupture is massive.

Diagnostic Evaluation

  • History and clinical examination.
  • Often incidental most AAAs are asymptotic until rupture.
  • Risk factors screening.

Physical Examination

  • Palpable pulsatile abdominal mass (Expansile) above the umbilicus.
  • May detect a bruit on auscultation sensitivity – 68 – 82%.

Imaging Studies

Ultrasound (US)

  • First line tool for both screening and surveillance.
  • AAA is defined when the aortic diameter exceeds 3.0 cm measured outer edge to outer edge in anterior – posterior or transverse views.
  • Limitations include operator dependency and interference from obesity or bowel gas.

Advanced Imaging Modalities:

  • Computed Tomography (CT / CTA)
  • CT Angiography
  • Gold standard for detailed evaluation is especially useful preoperatively or in suspected rupture.
  • Comprehensive 3D anatomy including involvement of branch vessels presence of thrombus, calcification and surrounding structure.
  • Dual energy CT reduces radiation and contrast load, helps differentiate calcified plaques and detect Endo leaks more clearly.

Magnetic Resonance Imaging (MRI / MR angiography) (MRA):

            Alternative when CT is contraindicated offering high sensitivity without radiation exposure. Longer scan times and cost with potential patient discomfort and motion artifacts are limited.

Contrast enhanced Ultrasound (CEUS)

While not recommended routinely for surveillance of ruptured AAA’s CEUS can enhance detection of Endo leaks positive EVAR and may assist in detecting rupture or aorto canal fistula in hemodynamically unstable patients who cannot undergo CT.

CT – Ultrasound Fusion:                

            A promising innovation that combines the convenience of ultrasound with the anatomical accuracy of CT demonstrated better measurement consistency relative to CT alone.

Management

Risk Factor modification

  • Smoking cessation
  • Blood pressure control.
  • Lipid management.
  • Glycemic control
  • Weight management
  • Regular exercise and diet.

Medical Management

Pharmacological Therapy

Antihypertensive

  • B- Blockers – reduce aortic wall stress
  • ACE inhibitors / ARBs – Beneficial for blood pressure and possible protective effect.
  • Satins – Reduce cardiovascular morbidity and mortality.
  • Antiplatelet Therapy – not for aneurysm directly but for secondary prevention of cardiovascular events.

Patient Education

  • Symptoms of impending/rupture sudden severe abdominal back or flank pain hypotension pulsatile abdominal mass.
  • Emergency care instructions.
  • Importance of adherence of follow up.

Types of Surgical Repair

Open surgical repair (OSR)

Procedure

  • Midline abdominal or retroperitoneal incision.
  • Aneurysm opened and replaced with a synthetic graft (Dacron or PTFE)
  • Aneurysm wall closed over graft.

Advantages

            Long term durability.

Disadvantages

  • High perioperative morbidity & mortality
  • Longer recovery (7 – 14 days hospital stay)

Endovascular Aneurysm Repair (EVAR):

  • Percutaneous or femoral artery cut down.
  • Stent – graft delivered via catheter under fluoroscopic guidance.

Advantages

Less invasive, shorter hospital stay.

Disadvantages

            Lifelong surveillance with CT ultrasound.

Complications

OSR

            MI, Renal failure bowel ischemic, bleeding graft infections.

EVAR

Endo leak graft migration limb occultation need for re-intervention.

Preoperative nursing Care

Assessment

  • Monitor vital signs
  • Assess the abdominal pain / back discomfort
  • Monitor pulses in lower extremities.
  • Watch for signs of rupture sudden severe pain hypotension tachycardia pulsatile abdominal mass.

Patient Education

  • Explain disease process and surgical procedure.
  • Importance of smoking cessation, BP control medications.
  • Breathing exercises, incentive spirometry, coughing techniques.

Post Operative nursing Care

Hemodynamic Monitoring

  • Continuous BP, Hb, central venous pressure urine output (> 30ml/l) monitoring
  • Avoid severe hypertension
  • Avoid hypertension

Pain management

  • IV opioids, PCA if ordered.
  • Strict I & O charting.

Respiratory Care

  • Oxygen therapy if needed.
  • Prevent pneumonia atelectasis

Renal monitoring

  • Serum creatinine, urine output.
  • Especially after EVAR.

Wound / Access Site care

  • Inspect incision or grain puncture site bleeding hematoma, infection.

OTI care

  • Monitor for abdominal distension bowel sounds.

Discharge & Long-term nursing Care

Patient Teaching

  • Medication adherence.
  • Lifestyle modification: no smoking healthy diet, weight control exercise.
  • Wound incision site care.
  • Report symptoms: severe abdominal / back pain dizziness, fainting leg pain absent pulses.

Surveillance

  • Regular follow up imaging
  • (EVAR: 1 month, 6 months yearly)

Nursing Diagnosis

  • Risk for infective tissue perfusion related to aneurysm of graft complication.
  • Acute pain related to surgical incision or aneurysm pressure.
  • Risk for impaired of as exchange
  • Deficient knowledge about disease.

Reference

  • Altobelli E, Rapacchietta L, Profeta VF, Fagnano R. Risk Factors for Abdominal Aortic Aneurysm in Population-Based Studies: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2018 Dec 10;15(12) [PMC free article] [PubMed]
  • Medical Advisory Secretariat. Endovascular repair of abdominal aortic aneurysm: an evidence-based analysis. Ont Health Technol Assess Ser. 2002;2(1):1-46. [PMC free article] [PubMed]
  • Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, Esvs Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document Reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019 Jan;57(1):8-93. [PubMed]
  • Kuivaniemi H, Ryer EJ, Elmore JR, Tromp G. Understanding the pathogenesis of abdominal aortic aneurysms. Expert Rev Cardiovasc Ther. 2015;13(9):975-87. [PMC free article] [PubMed]
  • Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, Mastracci TM, Mell M, Murad MH, Nguyen LL, Oderich GS, Patel MS, Schermerhorn ML, Starnes BW. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018 Jan;67(1):2-77.e2. [PubMed]

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