Introduction
Aortic aneurysm is defined as a permanent segmental dilatation, greater than 50% of the normal diameter of the proximal aortic segment1. This dilatation can be baggy or spindle2. In practice, according to the French Society for Vascular Medicine, an abdominal aortic aneurysm is suspected when the antero-posterior diameter exceeds 3 centimeters. All territories of the aorta may be involved, but the most frequent is the one located in the sub-renal area followed by popliteal aneurysms3,4.
Aortic aneurysms are important causes of mortality, in developed countries such as in the United States of America where, arterial aneurysms and their ruptures were responsible for approximately 15,000 deaths per year in 2013 and this could be just the tip of the iceberg1. Studies have shown that the incidence of ruptured abdominal aortic aneurysms (AAA) in sudden deaths is 4 to 5%. The number of deaths due to AAA rupture would then amount to 3000/year, a mortality comparable to that of prostate cancer (32,000) and breast cancer (42,000) 5;.
In sub-Saharan Africa, arterial aneurysms are uncommon and probably poorly evaluated, as the situation is particularly characterized by a scarcity of vascular surgeons and an insufficient technical equipment’s. Nevertheless, with the aging of the population and the increase in cardiovascular risks, the incidence of aneurysms is beginning to rise. It has been reported in Mali in 2009, over a period of 2 years, 7 cases of AAA, whereas 30 cases were collected over a period of 16 years in South Africa6. In Madagascar, data on the pathology of sub-renal aortic aneurysm are still rare, no protocol has been established for its surgical management1.
The main risk factors for developing an abdominal aortic aneurysm are age, male gender, hypertension and hypercholesterolemia, smoking and family history of aneurysmal pathology7.
Indeed, the male population over 65 years of age is the most affected and represents 5% of aortic aneurysmal pathology, moreover with equal diameter, the risks of rupture are higher in women and the reasons evoked are accelerated growth in women as well as aneurysmal dilatation5.The antero-posterior diameter is the main risk factor, if any AAA can rupture and the risk of rupture increases with the AP diameter of the AAA. The threshold of 55 mm of AP diameter appears to be particularly significant, many studies have been devoted to the risk of rupture according to the diameter of the AAA, a synthesis has been proposed by the joint council of the American Association for vascular Surgery and Society for Vascular Surgery according to which the risk of rupture is imminent at this stage 8.
The majority of AAAs are asymptomatic and are detected as an incidental finding on ultrasound, abdominal CT, or magnetic resonance imaging performed for other purposes. It may also manifest as abdominal pain or complications such as thrombosis, embolization and rupture. Approximately 30% of asymptomatic AAAs are discovered as a pulsatile abdominal mass on routine physical examination 8.
Repair options include surgical repair (including trans-abdominal or retroperitoneal) or endovascular repair, the latter of which involves insertion of a stent graft into the lumen that effectively excludes the aneurysm from blood flow, thereby minimizing the risk of rupture; endovascular repair of an AAA is a less invasive and less expensive alternative to open surgical repair. The short-term success rate for endovascular aneurysm repair ranges from 83% to more than 95%. For surgical repair, 30-day mortality in the major randomized trials ranges from 2.7% to 5.8% and is influenced by the volume of procedures performed in the hospital and the expertise of the surgeon. One review concluded that all-cause mortality at 30 days post-procedure was significantly lower with endovascular repair compared to surgical repair at 1.6% versus 4.8%, however, studies have shown no long-term benefit of the endovascular approach compared to surgical repair at one to two years8
In the Democratic Republic of Congo, to our knowledge, there was no published data found on AAA, hence we aimed at reporting two cases operated on at the Department of Surgery of Referral Hospital of Katana.