here’s what we can find out about it.
back up it’s a balloon-like dilation of some part of the abdominal aorta, between where the diaphragm hits it and where it bifurcates into the common iliac arteries. in other words, in the abdomen. how groundbreaking is that? that the triple A happens within the abdomen, between the diaphragm and the iliac bifurcation?
it happens due to a failure of the arterial wall, which feels like an understatement and a nothingism, but we persist.
it’s defined by an aortic diameter greater than three centimeters.
eighty percent of all of them occur between the renal arteries and the iliac bifurcation. so that must imply that the remaining twenty percent would occur between the diaphragm and the renal arteries, then. cool...... yeah, that sounds fine to me.
it can be suprarenal, pararenal, or infrarenal, with 85% being infrarenal..... not sure how that coincides whith what i just said about the betweenness of them with the diaphragm and bifurcation, but that’s okay.
ninety percent of AAA patients have a smoking history….. and of all the men who are old and who have smoked, five percent of them will get an AAA. so it’s not like the most common thing in smokers, but you got a one in twenty chance of getting it if you decide to smoke and also decide to live to old age.
this is a disease that men love getting, and they get it three times as much as women do. for every one woman who gets AAA, three men get it. sexism…….. or something…. or maybe sexual justice somehow…. like, ladies, you can take all the internalized misogyny and externalized misogyny coming in from other people that you then internalize, if it’s okay with you…… then we’ll give you this advantage of having less likelihood of getting an AAA. is that fair? i’m not sure. we’ll leave it up to our beautiful queens to decide.
smoking, let’s talk smoking again, because it’s the number one modifiable risk factor. so just don’t smoke!!! don’t do it!!!!! ninety percent of AAA patients have smoked!!!! let's just say that once again!!!! it’s so important! don’t smoke or you’ll get AAA………. yeah, let's leave it at that.
if your sibling has an AAA, and you’re a male, then you have like a thirty percent chance of screening positive for AAA yourself. so it seems like this shit runs in families, especially if you are someone who is male and you have a sibling who had one. so yeah……
AAA enlarges slowly over the course of years, and the bigger it is the faster it gets bigger. seems like a recipe for it popping, does it not? like yes, the bigger a balloon gets the faster it gets bigger, and then i think the subtext of that is that the more likely it is for it to pop. sounds scary to me but we’ll keep reading.
the rupture rate is one percent per year if the AAA is between 4 and 5.5 cm, 10 percent per year if it’s greater than 5.5 cm, and about 25 percent over six months when it’s bigger than 8 cm. so like bigger than 8cm is the real danger zone. if it’s bigger than 8, it’s about to ate you up…. or something?
most people who have AAA will find it on getting screened at age 65. getting screened decreases the rate of rupture by fifty percent and reduces aneurysm-related mortality by forty percent……. though overall mortality, like all cause mortality, is not decreased with screening. so yeah, if the aneurysm is gonna be the thing that kills you, then sure, it’ll kill you less of the time if you find it on screening. that seems pretty obvious and not all that groundbreaking. cuz like you get this invasive procedure, i’m assuming, to correct it, do you not?
anyway, it’s usually asymptomatic before it ruptures, but you might get back pain, flank pain, abdominal pain, and claudication. these can all occur prior to rupture and let you know that you gotta keep an eye on something type shit. you might also see blue toe syndrome, and this is actually the presenting symptom in five percent of patients.
that seems like a good little pearl to remember. the triple A is going to make your toe blue, so like if someone comes in with a blue toe you better be thinking about AAAA. don’t worry, i will.
remember that AAAs can be asymptomatic and incidentalomas found on abdominal exam or imaging.
the rupture can be diagnosed by finding blood in the retroperitoneum. that’s like the key to diagnosing it, really.
depending on how it presents in terms of symptoms, an AAA can be misdiagnosed as acute GI illness like bowel ischemia or peptic ulcer, or even GU disease like stones or infection, as well as spinal disease. you gotta be careful there and really do a history and physical i’m assuming. man, i forgot about medicine. it’s all so very logical, isn’t it?
if you wanna find out if someone has an unruptured AAA, do an abdominal ultrasound. to diagnose a rupture, though, you gotta do something more intensive and that is a CT scan……….. or MRI.
if you find that they have a ruptured AAA, that’s a surgical emergency and you gotta call the vascular surgeon to fix it. right away!!!!
we recommend surgery forrrr unruptured AAA when you have one bigger than 5.5 cm in a man, or if the person is a good surgical candidate. in other words, if it’s a woman and it seems like she’d be open and responsive to surgery, you can go ahead and get it fixed…. but the threshold might be lower for women. we don’t know.
the ruptured AAA has an 80% mortality rate and the life exepctancy after you have one repaired is 8 years for a 75 year old and 11 years for a 65 year old. seems like death still wants to come when it wants to come, y’all. we can intervene, but we’ll be adding only years…. which i guess could be meaningful, but i wouldn’t put all my hopes into it….. idk i’m sort of just generally losing hope in medicine with each passing day, even when i read that something like vascular surgery can add such a significant number of years to someone’s life…. i just don’t know man…… what kind of life is that…. it’s not for me to say. let’s move on.
this is the 14th leading cause of death in the US, and up to nine thousand people die each year due to a rupture. it’s the 10th leading cause among elderly men, and it’s rarely ever seen in people under the age of fifty. seems reasonable and fair to me. seems pretty fair actually, yeah………
the prevalence in those over 50 is three to 10 percent depending on risk factors. so like a smoker would have a much higher risk of getting it as we know very well now.
prevalence, as we’ve said, and as i’ll say again right now, is a function of gender and smoking. period. we can put it all kinds of different ways, including how we’ve put it already, and we can also say that smokers are five times more likely to develop AAA than non smokers.
ooh, here’s something curious. assuming you have a man and a woman who both already have AAA, the woman is more likely to get it to rupture. what’s that about? that’s kinda crazy. she’s four times more likely for it to rupture. interesting stuff, interesting stuff……..
whiteness is also a risk factor for it. that feels good and fair. like yes we need these whities to get taken down any means necessary and i think it’s good but also it might also not be good for us and society that it’s more likely for white people to get it. like maybe that just means that the non-whities aren’t living past fifty so much… or they’re dying of things more sinister….. who knows, who knows.
importantly, and i don’t know if i’ve emphasized this yet, but most of them do not rupture. if they do, you’re most likely gonna die, but if you’ve got one, it’s most likely not gonna rupture. so don’t worry but also worry a little bit. maybe. like……… don’t worry because you probably won’t get killed by it, but if you do, then that’s just the way it is lol.
it’s easier to diagnose AAA via ultrasound if you have claudication. so like someone coming in with claudication and a blue toe should be thoroughly considered for AAA just like get it out of the way and do the imaging that you wanna do…… if you suspect that it ruptured, remember that you’d do a CT.
what about screening? we can sort of somewhat recommend a one-time screening for men aged 65 to 75 who have ever smoked. otherwise we don’t really screen, we don’t really do it. ultrasound is how we screen. surveillance is every three years, unless it gets a little bigger, then you do it every year.
importantly though, screening can also be dangerous and add to misuse of the system. because screening doubles the rate of AAA surgery. do what you will with this info, but for me, when i think of how most of them don’t even rupture, i’m just like… okay so this is really redundant. you know? like why are we correcting so many things that are not going to rupture? it’s anxiety and neurosis it’s all that shit and it’s colonization allowing us to do these things on people….. ugh i hate medicine so much dude lol.
most of the people with AAA die from something else. they die with the AAA rather than from the AAA. like hello. even if it’s bigger than 5 cm they’re usually not dying from it.
my god dude, the risk of death while in surgery is 7% in women and 5% in men when you do an open surgery, and it goes down to 2 and 1 percent when you do it endovascularly. so like…. let’s not do the surgery. in my opinion. let’s not do it unless it ruptured and the person is like please i don’t wanna die. then i guess we could do it, but even then…. lol i’ll stop here and let y'all be the judges.
in terms of risk factors, there’s one more that we heaven’t mentioned, and that is south asian ancestry. there are also other ones like hypertension and high cholesterol and of course smoking and male gender i’ll say them again once more.
if we’re assessing for it on physical exam, we’re going to go ahead and look for a widened aortic pulsation or abdominal palpation or an abdominal pulsatile mass near the umbilicus….. these are all going to be sort of decent for finding a AAA, but of course you’ll wanna do ultrasound to really make sure cuz the sensitivity and specificity of that is much higher than palpation alone.
reminding you that diagnosing a rupture requires finding blood in the retroperitoneum or abdomen. just flagging that for you again.
i want to mention here that although i said that ruptured AAA leads to death 80% of the time, that’s IF it gets diagnosed. if someone’s AAA ruptures and it doesn’t get diagnosed, that is always going to kill you. it’s always going to kill if it’s not diagnosed, which makes sense, right…. it makes sense. we don’t need to walk through all the ways that it would kill you. it’s that you’re bleeding inside to death. that’s pretty simple.
the best thing to do for it is to quit smoking. former smokers have less risk than active smokers. just stop smoking, guys, if you don't want to die from this thing.
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well, there’s nothing really to do but keep going, is there? i look out the window and see the american flag in a battle against the tree adjacent to it. it’s snagged in the branches. the tree is clearly winning, and the wind is trying to help the flag get out of that entanglement. but the tree is not letting go, and it is with this symbol that i will leave you as we move on to
the next thing