Clinical Commander

All dossiers
vasc.aaa.v1

Abdominal aortic aneurysm (surveillance + rupture)

vascularacutechronicadultacuteoutpatienttransition
Start encounter →Print handoutPRODUCTION

5-step regimen (surveillance + medical optimization → elective repair → post-repair surveillance → ruptured pathway → mycotic) authored with RxCUIs from vasc.aaa.v1 manifest rxnorm_codes block; outpatient + ED + transition setting playbooks; six severity triggers including rupture, rapid expansion, mycotic, CTD, endoleak, suspected unstable. No `_design-brief.md` in src/lib/tier3/problem-package/packages/abdominal-aortic-aneurysm — author one before promoting to PRODUCTION. Manifest cites ESVS 2024, NICE NG156, SVS 2018, ACC/AHA 2022, ESC 2024, RCEM 2019, NHS screening — without inline PMIDs; backfill on next research pass. No AAA-specific calculator (Glasgow Aneurysm Score, Hardman index, ESVS perioperative risk) yet in clinical-tools-registry.ts — flag before PRODUCTION.

Entry points (4)

  • symptom
    Pulsatile abdominal mass on exam (SVS 2024)
    pulsatile_abd_mass
  • symptom
    Abdominal/back pain + hypotension/syncope — rupture suspicion (ESVS 2019; SVS 2024)
    abd_back_pain_with_hypotension
  • imaging
    US/CT showing infrarenal aorta >=3.0 cm (SVS 2024; ESVS 2019)
    us_or_ct_aaa
  • problem_list
    NHS / USPSTF AAA screening — men 65-75 / select women (USPSTF 2019; ESVS 2019)
    screening_eligible

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Screening criteria + repair threshold + life expectancy (SVS 2024; ESVS 2019)
  • sexrequired
    demographic • used at CONTEXT
    Repair threshold lower in women ~5.0 cm vs 5.5 cm (SVS 2024; ESC 2024)
  • sbprequired
    vital • used at RED_FLAGS
    Permissive hypotension SBP 70-90 mmHg in suspected rupture (ESVS 2019)
  • hrrequired
    vital • used at RED_FLAGS
    Hemodynamic monitoring + tachycardia screen (SVS 2024)
  • cta_aortarequired
    imaging • used at INITIAL_WORKUP
    Definitive sizing + rupture/contained leak detection (SVS 2024; ESC 2024)
  • aortic_us
    imaging • used at INITIAL_WORKUP
    Screening + surveillance imaging (ESVS 2019; USPSTF 2019)
  • creatininerequired
    lab • used at CONTEXT
    Contrast planning; renal artery involvement (SVS 2024)
  • crp
    lab • used at BRANCHING_WORKUP
    Inflammatory / mycotic phenotype (ESVS 2019)
  • blood_culture
    lab • used at BRANCHING_WORKUP
    Mycotic AAA workup (ESVS 2019)
  • smoking
    history • used at CONTEXT
    Strongest modifiable risk factor + smoking cessation (SVS 2024; ESVS 2019)
  • family_history_aaa
    history • used at CONTEXT
    First-degree relative -> earlier screening (SVS 2024; ESVS 2019)
  • connective_tissue_disorder
    history • used at CONTEXT
    Marfan / EDS-vascular / Loeys-Dietz lower threshold (ESC 2024)

12-phase flow (12)

  1. 1FRAME
    Differentiate stable surveillance vs symptomatic / ruptured emergency (SVS 2024; ESVS 2019)
    inputs: sbp
    advance: phenotype assigned
  2. 2ENTRY
    Capture trigger — screening / incidental / symptomatic (SVS 2024; USPSTF 2019)
    inputs: age, sex
    advance: entry trigger captured
  3. 3CONTEXT
    Smoking, family history, connective-tissue disorder, comorbidity / fitness for repair (SVS 2024; ESC 2024)
    inputs: smoking, family_history_aaa, connective_tissue_disorder, creatinine
    advance: context complete
  4. 4RED_FLAGS
    Rupture suspicion -> permissive hypotension SBP 70-90 + STAT vascular + MTP; hemorrhagic shock (ESVS 2019)
    inputs: sbp, hr
    actions: acute_abdomen
    advance: rupture pathway activated or excluded
  5. 5INITIAL_WORKUP
    Aortic US (screening ESVS 2019); CTA for sizing / morphology / EVAR anatomy (SVS 2024); BMP, CBC, coag, type-and-screen
    inputs: cta_aorta, creatinine
    actions: panel.renal, panel.coag, panel.cbc
    advance: sizing + morphology documented
  6. 6BRANCHING_WORKUP
    Mycotic / inflammatory phenotype workup — BC, CRP, ESR, FDG-PET (ESVS 2019); thoracoabdominal extension; iliac involvement
    inputs: crp, blood_culture
    advance: phenotype subtype documented
  7. 7DIFFERENTIAL
    Infrarenal vs juxtarenal vs thoracoabdominal; saccular vs fusiform; mycotic vs inflammatory vs degenerative (SVS 2024; ESC 2024)
    advance: classification documented
  8. 8RISK_STRATIFICATION
    Repair threshold >=5.5 cm men / >=5.0 cm women / rapid expansion >1 cm/y / saccular / symptomatic (SVS 2024; ESC 2024); surveillance interval otherwise (ESVS 2019)
    inputs: age, sex
    advance: repair vs surveillance decision documented
  9. 9TREATMENT
    Ruptured / symptomatic -> EVAR-first (ESVS 2019 Class I; EVAR-1 Greenhalgh Lancet 2004) with permissive hypotension and MTP; elective EVAR vs open repair per anatomy + fitness (SVS 2024); medical optimization — smoking cessation, statin, BP control; mycotic -> long-course IV abx + early repair (ESVS 2019)
    inputs: sbp
    advance: repair plan and medical optimization documented
  10. 10DISPOSITION
    Symptomatic / ruptured -> vascular OR; elective surveillance -> vascular surgery clinic (SVS 2024); med optimization in primary care
    advance: disposition assigned
  11. 11MONITORING
    Surveillance interval by size (ESVS 2019; SVS 2024); post-EVAR endoleak surveillance — CT/duplex 1, 6, 12 mo then annual (SVS 2024); post-open follow-up
    advance: surveillance plan documented
  12. 12FOLLOWUP
    Long-term smoking cessation; BP and statin optimization; family screening recommendations (SVS 2024; ESC 2024)
    advance: long-term plan in place