This instance survey is about an 80 old ages old male with symptomless abdominal aortal aneurism who presented to his GP with other symptoms unrelated to abdominal aortal aneurism. The writer will analyze the diagnosing of his aneurism, the mode used, the intervention and direction. Diagnosis and intervention tracts shall be followed ; analysis and comparing to other tracts shall be done to see which is the most effectual and accurate in the diagnosing and intervention of abdominal aortal aneurism. Patient confidential information shall be maintained throughout this essay, therefore in line with the codification of professional behavior, Nursing and Midwifery Council ( 2008 ) .
Case study
80 old ages old, Mr X, of height 5 pess 8 tall who weighted 50 kilograms presented to his GP on the 6th of February 2010 with 6 yearss history of irregularity. During physical scrutiny a throbing mass was noted in his venters. The patient had no symptoms related to aneurysm, such us back or abdominal hurting. The GP discovered during conversation with Mr X that his brother died from rupture AAA a twelvemonth ago. Mr X smokes 3 battalions of coffin nails daily. His past medical records showed that, he had chronic clogging pneumonic disease, high blood pressure, ischemic bosom disease which he had a beltway surgery 15 old ages ago. He besides had an MI 2 old ages ago holding had transdermal conary intercession ( PCI ) to circumflex and right coronary arterias.
The GP suspected that Mr X had an AAA and referred him for ultrasound scan to govern out the size of AAA. The ultrasound scan was conducted two hebdomads after seeing the GP. The scan revealed an aortal aneurism below the degree of the nephritic arterias mensurating 5.99 cm A-P diameter. Mr X was referred to a vascular sawbones who recommended a CT scan to look into the extent and anatomical construction of the aneurism to see Mr X ‘s suitableness for endovascular repai
Computer Tomography Angiogram aorta was performed a hebdomad after the ultrasound scans. CT angiogram with contrast showed a big infra-renal abdominal aortic aneurism which measures maximally 6 centimeter in diameter. It besides demonstrated good infra-renal cervix.
Ultrasound of the venters showing an infrarenal aortal aneurism steps 5.99 centimeter. ( Local NHS Trust 2010 )
Axial CTA with contrast of the venters demoing infrarenal aortal aneurism mensurating 6 centimeter ( pointers ) with partial calcified integral wall
( Local NHS Trust 2009 )
The sawbones so referred Mr X for an elected vascular surgery because his aneurism was big and carried a high hazard of rupture and decease.
One hebdomad before his surgery, Mr X had a chest X ray, blood trial and EKG which were all normal.
On the twenty-four hours of admittance, his pulsation was 68BP/min and regular with a blood force per unit area of 140/80 mmHg.
The below tabular array shows pre-assessment blood probes done.
Blood Test
Mr X ‘s consequence
Normal Laboratory Test Values
Entire white blood cell count
6.56 M/mcL
3.8 M/mcL to 5.6 M/mcL
hemoglobin
14 g/dL
11 g/dL to 18 g/dL
Platelet count
160
150-400
Red blood cell count
5 M/mcL
3.8 M/mcL to 5.6 M/mcL
Bureau of intelligence and research
1.1
0.9-1.2
Blood urea N
6.86 mg/dL
6 mg/dL to 23 mg/dL
Creatinine
98 mg/dL
0.6 mg/dL to 15 ng/dL
( Tinkham 2009 )
Preoperative appraisal was done to give Mr X ‘s sawbones a image of his overall wellness position.
A complete blood count was performed to look into for the presence of infection, ensured an equal ruddy blood cell volume and regulation out serious haematological abnormalcy.
Electrocardiography ( ECG ) was performed to measure cardiac arrhythmias and diagnose cardiac upsets such as myocardial infarction.
Chest X ray was done to measure the presence of infection, bosom failure, emphysema and other status that may act upon surgical result.
Creatinine and urea were performed to place job with nephritic clearance preoperatively.INR trial was done to guarantee coagulating ability before surgery.
The International Normalized Ratio ( INR ) was done to guarantee blood coagulating ability before surgery
On the 30/ 4/2010, Mr X underwent an endovascular aortal fix and was transferred to intensive attention unit while proctor his status for 3 yearss. He was discharged and had a wholly recovery after a month. Mr X had a follow up postoperative ultrasound and field movie x beam of venters. X beam and ultrasound was conducted at 1and 6 months to look into the place of the stent transplant and endoleaks. However, the scan and ten beam showed no grounds of any complication.
Plain skiagraphy of venters at 1 month the unity and migration of Zenith stent transplant
Raad ( 2010 )
Discussion
AAA is a comparatively common and potentially dangerous status associated with old age. The bulk of abdominal aortal aneurisms do non do any symptoms and hence diagnostic is frequently missed. In many instances, the exact cause of aneurism is still ill-defined. However, harmonizing to Baker ( 2009 ) , the primary cause of aortal aneurism is atherosclerosis and other factors for case, male over 65 old ages, smoke, a positive household history, COPD and high blood pressure contribute to the hazard.
An probe of Mr X ‘s AAA was done during a physical scrutiny of the venters which was conducted for other grounds. Approximately 75 % of abdominal aortal aneurisms are symptomless and are found by the way during abdominal physical scrutiny or radiographic probes ordered for other conditions, ( Anderson et al 2001 ) . Aneurysm tactual exploration on physical scrutiny has merely been shown to be sensitive in thin patients and those with abdominal aortal aneurism & A ; gt ; 5 centimeter with an overall sensitiveness and specificity of 68 % and 75 % , severally for sensing of AAA, ( Fink et al 2000 ) .
The primary mode used to corroborate Mr X ‘s aneurysm size was made by ultrasound. Ultrasound is a standard image mode for an probe of suspected symptomless and surveillance of abdominal aortal aneurism. Ultrasound is safe, non-invasive, comparatively cheap, widely available and does non expose patient to radiation. It is the best option for observing and mensurating the size of aneurism. However, harmonizing to Sparks et Al ( 2002 ) ultrasound can non accurately specify the extent of the aneurism as it can be altered by intestine gasses, and hence is unequal for preoperative planning of endovascular fix.
Computerized Tomography Angiogram ( CTA ) of the venters was the 2nd mode to be used to look into the extent of Mr X ‘s abdominal aortal aneurism and the aneurysmal cervix for preoperative planning. CTA is going the diagnostic imagination mode of pick in the preoperative appraisal of patients with an abdominal aortal aneurism. However it has some disadvantages for case, it uses high doses of radiation, cost effectual and requires endovenous contrast but it is faster and extremely accurate in finding the size and extent of the aneurism, and its relation to the nephritic arterias. ( Hafez 2009 ) .
The other mode that could hold been used for preoperative planning for Mr X ‘s abdominal aortal aneurism is magnetic resonance angiogram ( MRA ) . Harmonizing to Aburahma ( 2007 ) , MRA is merely used for surgical planning fix when CTA contradicts with patients with contrast allergic and nephritic failure. However, both computerized imaging and magnetic resonance imagination are effectual for preoperative planning fix. CTA and MRA imaging provide high-resolution imagination of the aorta and find proximal and distal boundaries of the aneurism, says ( Upchurch 2009 ) .
MRI scan is comparatively clip devouring, really expensive and may be distorted by gesture artifact, extended calcified plaque and metallic surgical stents Upchurch ( 2009 ) . Hence, MRA is non used for preoperative appraisal of endovascular fix. Mr X ‘s preoperative mode was good as he did non hold any contraindication such as contrast allergic reaction or nephritic failure for him to undergo a magnetic resonance angiogram scan. With magnetic Resonance Angiogram, endovenous dye is non required and it does non expose the patient to radiation as compared to Computer Tomography Angiogram, ( Truijers 2009 )
The primary end of intervention depends on the size of the aneurism, the possibility of rupture and the patient ‘s status. The purpose of surgical intervention is to forestall aneurism from rupture for patients with symptoms such as back hurting, or symptomless aneurism greater than 5.5 centimeter in diameter, ( Hakaim 2006 ) . When sing intervention of abdominal aortal aneurism there are two types of fix ; unfastened fix and endovascular aneurism fix.
Endovascular aortal fix ( EVAR ) was recommended as the most appropriate intervention for Mr X taking into history short and long term hazards and the benefits of both processs in relation to his age and co-morbidity every bit good as anatomical suitableness. This Endovascular aortal fix is a safe process and can be efficaciously performed in a patient with the suited anatomy for illustration, a individual with infrarenal aortal diameter no larger than 26 millimeters and aortal cervix length at least 15-20mm without inordinate angulations, ( Hallett 2009 ) . However, in such patients with a suited anatomy and surgical expertness, increasing the usage of endovascular aortal fix is likely justified based on its better preoperative result informations ( Hallett 2009 ) .
EVAR relies to a great extent on nomadic C-arm image intensive. This enables the sawbones to utilize x-ray images to visualize the interpolation of stent transplant through the femoral arteria up to the site of the aneurism while being imaged. However, this it exposes patient to radiation during the process and in subsequent follow up
EVAR is a less invasive process with a potentially reduced morbidity, mortality of 1.6 % , intensive attention, entire infirmary stay and a rapid recovery clip comparison to open fix with morality of 4.6 % , ( Tinkham 2009 ) . In the prospective randomized controlled tests, EVAR has been shown to hold a significantly better preoperative result, ( Tinkham 2009 ) .
In contrast to EVAR, unfastened fix requires a surgical exposure of the aorta clamping. Open fix was non recommended for Mr X because of hapless province of wellness due to his medical co-morbidities which limit his day-to-day activities. Harmonizing to Anderson ( 2009 ) , unfastened fix is non suited for patients with co-morbidity including terrible chronic clogging pneumonic disease or myocardial misdemeanor which places at high hazard.
EVAR carries a higher hazard of complications which would necessitate farther surgery to rectify. This requires postoperative long-run follow-up imagination as the long term lastingness of the stent transplant remains unsure, ( Liaw et al 2009 ) .
Mr X underwent a postoperative follow up obviously abdominal x beam and ultrasound at 1 month to look into the stent transplant unity and migration. Plain skiagraphy is easy to obtain and widely available. It still plays a utile function in measuring the metallic unity of the stent transplant but the truth of endoleaks is limited. However, the field movie can be used in concurrence with ultrasound as a method of follow up, ( Mattes et al 2011 ; Ginter et al 2009 ) . Duplex ultrasound imaging is non-invasive compared to CT. Studies show that duplex ultrasound had a sensitiveness of 90 % while CT had of 58 % in sensings of endoleaks, ( Badri et al 2010 )
Contrast-enhanced CT is another imaging mode that could hold been used for Mr X ‘s postoperative endovascular aortal fix. This image mode is expensive, less accurate in sensing of little endoleaks and it exposes patients to radiation and is. However, the major concern sing the frequent usage of contrast-enhance CT including additions cost and cumulative radiation doses which leads to lifetime malignant neoplastic disease hazard to patients have shift toward color semidetached house ultrasound, ( Mattes et al 2011 ) .
MRA is alternate mode could hold been used for postoperative rating of Mr X ‘s stent transplant fix. Mr X can non undergo MRA as his aneurism was treated with Zenith stent transplant which may be distorted by gesture artifact in the magnetic field. Harmonizing to Liaw et Al ( 2009 ) , MRA is every bit accurate as CTA for sensing of endoleaks but is really expensive and can non be usage to image ferromagnetic stent transplants such as Zenith. Hence, MRA is non utile for postoperative rating of patients with stent transplants
Decision
I think the tract taken to name Mr X ‘s abdominal aortal aneurism was right and besides the most current pattern taken in many infirmaries. Endovascular aortal fix is a less invasive process with a potentially decreased morbidity and mortality. Endovascular aortal fix has been widely performed and it is an effectual option to open fix, peculiarly for patients with medical comorbidities. However, the mandatary follow up after is a disadvantage of this technique.
Despite the disadvantages, CT remains the most widely used mode in preoperative planning for abdominal aortal aneurism and postoperative surveillance after endovascular aortal fix. In contrast to computing machine imaging, ultrasound is the simplest, cheapest, mode used for suspected and surveillance of AAA. It is a standard mode used in concurrence with field movie in some infirmaries for follow up after endovascular aortal fix. Overall, imaging provides an spread outing aggregation of tools, leting progressively accurate probe of AAAs and patient choice for endovascular aortal fix. Surgeons and radiotherapists in this field should be cognizant of the technological betterments in each imagination mode, to do the right picks before, during and after endovascular aortal fix
