1. Inflammatory Abdominal Aortic Aneurysm with Obstructive Nephropathy in a 71 yr old MaleBy
Chijioke Chinaka

2. T/F a peripheral Hospital
HS, 71 yr Old Male
Background
Hypertension
Asthma
T/F a peripheral Hospital
Incidental finding of 10cm Non leaking AAA
On treatment for PE
Presentation
Left upper leg pain
Swelling
Cellulitis on the foot
Abdominal pain0, back pain0, urinary symptoms0
Examination/investigations
Swollen tender upper left leg; Duplex scan
LIF mass; CT

3. CT SCAN Inflammatory Aneurysm Hydronephrosis Over Distended Bladder
Bilateral thrombo ilio-femoral veinous system

4. Hydronephosis
Over distended blader

5. Thrombosed ilio femoral venous system

6. Sagittal section

7. Examination Investigation Pulse 90b/min BP 120/80 mmHg Left Lower limb
Mildly swollen
Groin tenderness
Cellulitic dorsum of foot
Abdomen
Soft
Non tender pulsatile mass
Investigation
Bloods: Cr – 140 mmol/l, Urea – 4.1 mmol/l, CRP – 71, ESR – 42mm/hr, WCC – 8.78, Hb – 11.6

8. Impression - Inflammatory Aneurysm Issues
Non Ruptured massive AAA
Bilateral Hydroureter
Poor Renal Function
Plan
Urology consult
Nephrology consult
Work up for optimization
Urgent surgery

9. Nephrology Urology Continue protective measures N-acetyl cysteine
Fluids
Urology
Hydronephrosis 20 ?Bladder outlet obstruction
USS
PSA

10. USS PSA Bladder not trabeculated Prostate not enlarged Kidney
Right 9.7cm
Left 9.5cm
Right Hydronephorosis
No evidence of left hydronephrosis
PSA
Total PSA 2ng/ml
Free PSA 0.5ng/ml
Ratio 25%

11. Cr - 105, Echo – EF 50%, Surgery (2 options) Open Repair
Complicated
Difficult access
Fistulation
Endovascular Stenting (EVAR)
Suitability
Minimal access

12. EVAR(surgery) Post Op 6th Day Aorto – iliac + Fem - Fem cross over
Resolved left hydronephrosis
Persistent right

13. DISCUSION

14. Inflammatory Abdominal Aortic Aneurysm

15. Definition Incidence Aetiology A distinct sub group of AAA
exuberant inflammatory reaction
marked peri-aneurysmal and retroperitoneal fibrosis
dense adhesions of adjacent abdominal organs
Incidence
5% to 10% of all AAA
> Male (M:F = 30:1 to 6:1)
Mean Age; 62 to 68 yrs
Smokers 77% to 100%
Aetiology
Unknown >90%
Genetic factor (HLA –DR B1 locus)
+ ve FHx (17%)
Unlikely infective aetiology : Chlamydia pneumoniae.
?variant of retroperitoneal fibrosis.
Walker et al. Br J Surg 1972;59: , T. Tang et al EJVES Vol 29 Issue 4, 2005;
SS Nitecki et al J Vasc Surg 23 (1996) (5), pp. 860–868.

16. Pathophysiology Presentation Inflammation Infection Symptoms
Inflammatory cell infiltrate
Both in IAAA and non – IAAA but > in the later
Macrophages, T- lymphocytes and B- lymphocytes
Immune Response
Infection
Herpes simplex and Cytomegalovirus
Chlamydia pneumonia
Presentation
Symptoms
Usually symptomatic (80%)
Abdominal pain + back pain
Weight loss
Asymptomatic (20%)
A. Stella et al Ann Vasc Surg 7 (1993), pp. 229–238.

17. Diagnosis Signs Others CT Scan Ultrasound Scan MRI Nuclear Medicine
Tender pulsatile abdominal mass (15% to 30%)
Elevated ESR (40% to 88%)
Raised CRP
Auria (Rare)
Others
Ischaemic foot
Intermitent claudication
Diagnosis
CT Scan
Sensitivity 83.3%
Specificity 99.7%
Overall accuracy 93.7%
Ultrasound Scan
MRI
Nuclear Medicine

18. Inflammatory AAA
Atherosclerotic AAA
Younger patient
Usually symptomatic
Elevated inflammatory maker
Marked thickening of Aneurysmal wall
Fibrosis of Adjacent retroperitoneun
Less likely to rupture
Strongly related to smoking
Older patient
Usually asymptomatic
Unrelated
Less thickening of wall
Less fibrosis
More likely to rupture

19. Treatment Non Operative Operative
Extensive fibrosis
Steroid therapy
Risk of Rupture
Operative
Open Surgery
High technical difficulty
Increased morbidity/mortality rate
Longer operating time
Longer hospital stay
EVAR
Longer-term peri aneurysmal regression
Uretrolysis/Management of Related Pathology