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I have a 3.3 cm AAA and a smaller one, with some internal dissections.

Posted by paulwendzi @paulwendzi, 5 days ago

Hi, I'm male, 80, near Portland, Maine, fairly healthy, do weights/calisthenics 3x/week, line dance 2-3x/week. Diagnosed a year ago with AFIB, taking Metoprolol and Eliquis. Have had six AFIB episodes, lasting 6-12 hours, none since February. Memorial Day I went to a very busy ER with R abdominal pain, CT with dye showed diverticulitis. With treatment, that resolved OK. Back home, I read my CT report on My Chart, and was shocked to see this--something the busy ER doc never mentioned:

"Infrarenal abdominal aortic aneurysm (AAA) has developed since the prior exam of 2016. Transverse diameter of 3.3 cm. Suggestion of a focal moderate-sized limited dissection with the false lumen of about 1.6 cm. Probably equal to that of the true lumen. Dissection probably about 3 to 4 cm in length. Another short segment area of aneurysm and dissection in the distal aorta just above the bifurcation measuring about 2.8 cm in length. Aortic bifurcation patent. Iliac arteries are patent with atherosclerotic changes."

(Family History: My father had three heart attacks, the last was suddenly fatal. His brother, my uncle, passed suddenly from an aneurysm rupture. My first cousin, another brother's son, had heart attacks, passed suddenly from last one.)

Immediately got an appointment with PCP, she said watch your BP, avoid strenuous activities, and got me an appointment with a vascular surgeon for July 1. Said they would likely do more tests/measurements, monitor me for growth, etc. But she didn't have much insight on the severity or prognosis of the dissections mentioned. I'm on pins and needles now, waiting to see surgeon for more answers. My reading says smaller AAA's do OK with watchful waiting, but what about the kind of dissections in my AAA's? Are they potentially as bad as the suddenly catastrophic dissections I read about? Do they warrant an earlier surgical repair than the smaller AAA's themselves normally require?

Would appreciate it if anyone has some additional insight on this, or suggestions for me. Thank you.

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moonboy | @moonboy | 5 days ago

@paulwendzi What jumps out at me is that your aneurysm is still relatively small at 3.3 cm, but the report also describes what sounds like localized chronic dissections within the aneurysmal segment. Those are two different issues, and the second one is probably why your PCP wanted you seen by a vascular surgeon rather than simply telling you to come back in a few years. The good news is that nothing in the report sounds like the classic emergency situation people think of when they hear "aortic dissection." The catastrophic dissections you read about are usually acute tears of the thoracic aorta, often involving the ascending aorta near the heart. I survived a sudden a Type A1 aortic dissection in 2015, and it required emergency open-heart surgery with placement of a Dacron graft. What your CT describes sounds much more like a limited, localized dissection within an infrarenal abdominal aneurysm that was discovered incidentally rather than during a life-threatening event. Several things are reassuring for you:
1. You were not diagnosed because of collapse, shock, severe back pain, or signs of rupture.
2. The radiologist describes the dissections as limited and focal.
3. The aortic bifurcation and iliac arteries remain patent.
4. The aneurysm diameter is only 3.3 cm, which is well below the usual size threshold where elective AAA repair is considered.
5. The report does not describe leakage, rupture, impending rupture, or other emergency findings.

That said, the dissection component makes this more complicated than a routine small AAA. The vascular surgeon will likely want to determine:
1.How old these dissections are.
2. Whether they are stable or changing.
3. The exact anatomy of the true and false lumens.
4. Whether there are features suggesting increased risk of future enlargement.
5. Whether additional imaging of the entire aorta is warranted.

Your family history is also important. A father with significant coronary disease and a close relative who died from an aneurysm raises the importance of careful surveillance, although at age 80 degenerative vascular disease is much more common than an inherited aneurysm syndrome.As for whether dissections trigger earlier surgery, the answer is "sometimes, depending on the anatomy." There is no automatic rule that a 3.3 cm AAA with a localized dissection must be repaired. Many are managed with surveillance if they remain stable. The surgeon will be looking for specific high-risk features rather than relying solely on the aneurysm diameter. Between now and July 1, I would focus on the things you can control:

Keep blood pressure well controlled. Continue taking medications exactly as prescribed. Avoid maximal lifting, breath-holding, and heavy straining. Continue walking and normal daily activity unless instructed otherwise. Seek immediate medical attention for sudden severe abdominal pain, back pain, flank pain, fainting, or symptoms that feel dramatically different from your baseline.

One practical question for the vascular surgeon is: "Do you believe these dissections are acute, chronic, or indeterminate?" That answer will tell you a great deal about how concerned they are. Another good question is: "Would you normally follow a 3.3 cm AAA with surveillance alone if the dissections were not present, and how do the dissections change your recommendation?" From what you've described, I would be concerned enough to keep the July 1 appointment and take blood-pressure control seriously, but I would not interpret this report as suggesting you are walking around with the same kind of emergency dissection that sends people directly to the operating room. Peace.

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paulwendzi | @paulwendzi | 5 days ago
In reply to @moonboy "@paulwendzi What jumps out at me is that your aneurysm is still relatively small at 3.3..." + (show)
Profile picture for moonboy @moonboy

@paulwendzi What jumps out at me is that your aneurysm is still relatively small at 3.3 cm, but the report also describes what sounds like localized chronic dissections within the aneurysmal segment. Those are two different issues, and the second one is probably why your PCP wanted you seen by a vascular surgeon rather than simply telling you to come back in a few years. The good news is that nothing in the report sounds like the classic emergency situation people think of when they hear "aortic dissection." The catastrophic dissections you read about are usually acute tears of the thoracic aorta, often involving the ascending aorta near the heart. I survived a sudden a Type A1 aortic dissection in 2015, and it required emergency open-heart surgery with placement of a Dacron graft. What your CT describes sounds much more like a limited, localized dissection within an infrarenal abdominal aneurysm that was discovered incidentally rather than during a life-threatening event. Several things are reassuring for you:
1. You were not diagnosed because of collapse, shock, severe back pain, or signs of rupture.
2. The radiologist describes the dissections as limited and focal.
3. The aortic bifurcation and iliac arteries remain patent.
4. The aneurysm diameter is only 3.3 cm, which is well below the usual size threshold where elective AAA repair is considered.
5. The report does not describe leakage, rupture, impending rupture, or other emergency findings.

That said, the dissection component makes this more complicated than a routine small AAA. The vascular surgeon will likely want to determine:
1.How old these dissections are.
2. Whether they are stable or changing.
3. The exact anatomy of the true and false lumens.
4. Whether there are features suggesting increased risk of future enlargement.
5. Whether additional imaging of the entire aorta is warranted.

Your family history is also important. A father with significant coronary disease and a close relative who died from an aneurysm raises the importance of careful surveillance, although at age 80 degenerative vascular disease is much more common than an inherited aneurysm syndrome.As for whether dissections trigger earlier surgery, the answer is "sometimes, depending on the anatomy." There is no automatic rule that a 3.3 cm AAA with a localized dissection must be repaired. Many are managed with surveillance if they remain stable. The surgeon will be looking for specific high-risk features rather than relying solely on the aneurysm diameter. Between now and July 1, I would focus on the things you can control:

Keep blood pressure well controlled. Continue taking medications exactly as prescribed. Avoid maximal lifting, breath-holding, and heavy straining. Continue walking and normal daily activity unless instructed otherwise. Seek immediate medical attention for sudden severe abdominal pain, back pain, flank pain, fainting, or symptoms that feel dramatically different from your baseline.

One practical question for the vascular surgeon is: "Do you believe these dissections are acute, chronic, or indeterminate?" That answer will tell you a great deal about how concerned they are. Another good question is: "Would you normally follow a 3.3 cm AAA with surveillance alone if the dissections were not present, and how do the dissections change your recommendation?" From what you've described, I would be concerned enough to keep the July 1 appointment and take blood-pressure control seriously, but I would not interpret this report as suggesting you are walking around with the same kind of emergency dissection that sends people directly to the operating room. Peace.

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@moonboy Wow, what a wonderful, comprehensive reply! This is exactly the kind of detailed insight I was hoping for. The information is valuable to me to objectively understand my situation, help ease my worries, and prepare me for meeting with the surgeon. I will certainly adhere to all the precautions in the meantime. I really appreciate you taking the time and effort to evaluate my case like this. You are very well versed in the subject. I'm glad you survived your own aneurysm crisis and are helping others in this way. Thank you so much!

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moonboy | @moonboy | 5 days ago

No problem. Glad to help. Coming up on my 11th anniversary. I couldn’t be happier.

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