A 66-year-old man is seen by his internist for an annual evaluation. Past medical history is notable for HTN and tobacco use. His BP is 136/80 mmHg on monotherapy. Cardiac and abdominal examinations are unremarkable. He has a friend who was detected to have an AAA (Abdominal Aortic Aneurysm) on routine screening and asks his physician whether it is indicated for him to be screened.
Which of the following statements regarding AAA screening is correct?
Screening men >65 years old is associated with a reduction in aneurysmrelated deaths compared with unscreened men of similar ages. Guidelines to screen for AAA vary among different governing bodies. The United States Preventive Services Task Force (USPSTF) recommends one-time screening for any male former or present smoker between ages 65 and 75 years. They do not recommend screening in women based on the lower expected prevalence of AAA. Other vascular societies have less restrictive screening recommendations for men and women. However, screening in patients with first-degree relatives with AAA is recommended. Randomized controlled trials of ultrasound screening for AAA in predominantly men aged 65 to 75 years show a reduction in aneurysm-related mortality compared with unscreened age-matched controls. Ultrasound screening of at-risk patients in accredited laboratories is associated with sensitivities and specificities of over 90%, respectively. Repeat screening after a negative study is not recommended.
A screening abdominal ultrasound is performed in this patient and shows an infrarenal AAA of 5.5 cm. The patient is advised to undergo repair though wishes to consider the option of an endovascular stent graft (EVAR) rather than an open repair.
Which of the following statements is true regarding recommendations for AAA repair?
Inflammatory or infectious aneurysms should be repaired at any size. Two large trials of predominantly males showed that early elective AAA repair for aneurysms (4.0 to 5.5 cm) resulted in a similar mortality compared with medical therapy. Therefore, repair is generally indicated for asymptomatic AAA if:
However, since AAAs may rupture at smaller sizes in women and smaller men, repair should be considered at 5.0 cm or even smaller in low-risk candidates for repair.
Which statement regarding EVAR is correct?
Open repair and EVAR are associated with similar long-term mortality. Endovascular repair of AAA is an alternative to open repair. Comparative trials including EVAR and DREAM have demonstrated a lower short-term morbidity and mortality (at 30 days) for EVAR compared with open repair. However, in long-term follow-up mortality was similar for the two procedures. EVAR is associated with more complications including endoleaks and need for repeat interventions and may require conversion to an open procedure.
Which of the following statements regarding endoleaks is correct?
Endoleaks may occur as a result of retrograde flow of small arterial branches back into the aneurysm sac. Endoleaks refer to the occurrence of repressurization of the excluded aneurysmal sac after an EVAR procedure.
There are four main types:
Type II leaks are most common. Types I and III may require immediate reintervention, whereas type II can be monitored by repeat surveillance but may require repeat intervention if the aneurysm sac continues to expand.
A 38-year-old woman is admitted to the internal medicine service for chest pain. She is experiencing sharp chest pain unrelated to exertion and dyspnea for 2 days. Her family history is unknown since she was adopted. Past medical history is not well defined but notable for an uncharacterized connective tissue disorder. She was told at a younger age to avoid pregnancy.
Admission ECG and cardiac enzymes are negative. She is unable to exercise because of her symptoms and therefore is sent for an adenosine nuclear stress test. The test shows mild anteroseptal ischemia with no ECG changes. The cardiology service is consulted for a cardiac catheterization.
Physical Examination:
What do you recommend?
CTA of the chest and aorta. The patient’s history and examination has several features suggestive of Ehlers-Danlos syndrome. Since she has a low pre- and posttest probability of coronary ischemia, a cardiac catheterization is not advisable. The vascular type of Ehlers-Danlos syndrome (type IV) is associated with spontaneous or iatrogenic arterial or organ rupture (e.g., rupture of gravid uterus or intestines). Aortic complications including dissection and rupture can occur and therefore arterial puncture is generally contraindicated. A CTA of the chest and aorta would exclude pathologies found in Ehlers-Danlos syndrome, including aortic and pulmonary aneurysm and dissection.
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