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How not to miss a leaking abdominal aortic aneurysm

Vascular surgeon Professor Roger Greenhalgh outlines the key clinical features and pitfalls in diagnosing a ruptured aortic aneurysm

Vascular surgeon Professor Roger Greenhalgh outlines the key clinical features and pitfalls in diagnosing a ruptured aortic aneurysm

Worst outcomes if missed

This is a lethal condition, which few patients survive. Survival is only possible if the diagnosis is made rapidly and the patient transferred directly to an emergency vascular centre that can do rapid investigation and operative correction with a skilled team. It is no good sending to the nearest A&E.

Epidemiology

Leaking abdominal aortic aneurysm is the third most common cause of sudden death from UK coroners' statistics.

• Some 75% of patients die before reaching hospital.

• Of the 25% who survive on arrival to hospital, half die before reaching the operating theatre.

• Current average operative mortality for open repair of leaking aneurysm is in the region of 40%.

• There is early hope and expectation that a new technique – emergency endovascular aneurysm repair – under local anaesthetic can reduce operative mortality in suitable patients by 15% and trials are under way.

Symptoms and signs

41208031A typical abdominal aortic aneurysm patient is a male aged about 70. They are usually smokers. Some 90% have another form of arterial disease, such as intermittent claudication or carotid or coronary artery disease.

They may therefore have had TIAs or heart attacks or difficulty walking. With such a history, a patient who has sudden symptoms in the abdomen should provoke the suspicion of ruptured abdominal aortic aneurysm.

The patient is in collapse and frequently complains of pain in the back and is found to have a swollen, tense abdomen. Any patient who has acute abdominal pain and sudden illness should be presumed to have abdominal aortic aneurysm until proved otherwise.

It is often difficult to feel the abdominal aortic aneurysm or even an aneurysmal aorta because the abdominal wall is quite rigid and unyielding. The differential diagnosis is of peritonitis from perforation, for example, of the appendix or duodenum or acute pancreatitis with peritonitis.

Time should not be wasted trying to feel the abdominal aorta. A ruptured aneurysm should be assumed at the outset if the symptoms and signs exist.

41208032The aim should be to transfer the patient gently to a vascular emergency centre, equipped for aneurysm surgery if required and where a CT scan can be performed urgently.

The ambulance service should be alerted to the suspected diagnosis and the designated hospital warned so that the team can be ready for rapid evaluation when the patient arrives.

The patient is likely to be pale, cold and sweaty. Many patients with early leak of abdominal aortic aneurysm who survive have nothing more than a sudden onset of back or mild abdominal pain without explanation. There are examples of such pain lasting for days before diagnosis.

The patient should not be taken to a hospital where emergency vascular surgery is not available. There are frequent examples of patients being taken to A&E first, which wastes time as a transfer is required. This greatly increases the risk of mortality.

Minimal transfusion is optimal. Filling provokes bleeding.

Investigations

• First-line investigation is a CT scan, preferably in A&E.

• Ultrasound is useful but CT is better.

• Haemoglobin level is a useful second-line test.

Professor Roger Greenhalgh is head of the Imperial College Vascular Surgery Research Group, Imperial College London

Competing interests: none declared

questions herrings MRI of bulging aorta (centre) in patient with an aneurysm MRI of bulging aorta (centre) in patient with an aneurysm

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