Genetic Considerations

It is highly likely that there are genetic factors that make one susceptible to AAA. Recent work has provided evidence for genetic heterogeneity and the presence of susceptibility loci for AAA on chromosomes 19 and 4. Family clustering of AAAs has been noted in 15% to 25% of patients undergoing surgery for AAA. In addition, AAAs are seen in rare genetic diseases such as Ehlers-Danlos syndrome or Marfan syndrome

GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS

Abdominal aneurysms are far more common in hypertensive men than women; from three to eight times as many men as women develop AAA. They are 3.5 times more common in whites than in blacks/African Americans. The incidence of AAA increases with age. The occurrence is rare before the age of 50 and common between the ages of 60 and 80, when the atherosclerotic process tends to become more pronounced. Ethnicity and race have no known effects on the risk for AAAs.

2 Abdominal Aortic Aneurysm

^ ASSESSMENT

HISTORY. Seventy-five percent of AAAs are asymptomatic and are found incidentally. When the aorta enlarges and compresses the surrounding structures, patient complaints may include flank and back pain, epigastric discomfort, or altered bowel elimination. The pain may be deep and steady with no change if the patient shifts position. If the patient reports severe back and abdominal pain, rupture of the AAA may be imminent.

PHYSICAL EXAMINATION. Inspect the patient's abdomen for a pulsating abdominal mass in the periumbilical area, slightly to the left of midline. Auscultate over the pulsating area for an audible bruit. Gently palpate the area to determine the size of the mass and whether tenderness is present.

Watch for signs that may indicate impending aneurysm rupture. Note subtle changes such as a change in the characteristics and quality of peripheral pulses, changes in neurological status, and changes in vital signs such as a drop in blood pressure, increased pulse, and increased respirations. An abdominal aneurysm can impair flow to the lower extremities and cause what are known as the five Ps of ischemia: pain, pallor, pulselessness, paresthesias, and paralysis.

Because emergency surgery is indicated for both a rupture and a threatened rupture, careful assessment is important. When the aneurysm ruptures into the retroperitoneal space, hemorrhage is confined by surrounding structures, preventing immediate death by loss of blood. Examine the patient for signs of shock, including decreased capillary refill, increased pulse and respirations, a drop in urine output, weak peripheral pulses, and cool and clammy skin. When the rupture occurs anteriorly into the peritoneal cavity, rapid hemorrhage generally occurs. The patient's vital signs and vital functions diminish rapidly. Death is usually imminent because of the rapidity of events.

PSYCHOSOCIAL. In most cases, the patient with an AAA faces hospitalization, a serious surgical procedure, a stay in an intensive care unit, and a substantial recovery period. Therefore, assess the patient's coping mechanisms and existing support system. Assess the patient's anxiety level regarding surgery and the recovery process.

Diagnostic Highlights

General Comments: Because this condition causes no symptoms, it is often diagnosed through routine physical exams or abdominal x-rays.

Test

Normal Result

Abnormality with Condition

Explanation

Standard test: Computed tomography (CT) scan Abdominal x-ray

Negative study Negative study

Locates outpouching within the aortic wall

May show location of aneurysm with an "eggshell" appearance; AAA is evident by calcification in the anterior wall of the aorta, displaced significantly anterior from the vertebrae

Assesses size and location of aneurysm

Assesses size and location of aneurysm

Other Tests: Ultrasound of the abdomen; magnetic resonance (MR); aortography

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