Aneurysms

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Aneurysms

  1. 1. Arterial AneurysmsArterial Aneurysms
  2. 2. DefinitionDefinition Permanent localized dilatation of thePermanent localized dilatation of the affected artery over the normal diameteraffected artery over the normal diameter ~~ 50%50% ArteriomegalyArteriomegaly ~~ 100%100% AneurysmsAneurysms As the age increases, arteries becomeAs the age increases, arteries become stiffer, wider (aneurysm) and longerstiffer, wider (aneurysm) and longer (tortousity)(tortousity)
  3. 3. AetiologyAetiology Most by degenerative disease (atherosclerosis)Most by degenerative disease (atherosclerosis) Structural weakness & Haemodynamic forcesStructural weakness & Haemodynamic forces – Damage to, and loss of intimaDamage to, and loss of intima – Reduction in the elastin and collagen content of theReduction in the elastin and collagen content of the mediamedia – Collagen; tensile strength, adventitiaCollagen; tensile strength, adventitia – Elastin; recoil capacity, mediaElastin; recoil capacity, media Risk factorsRisk factors – smoking, hypertension, hypercholesterolaemiasmoking, hypertension, hypercholesterolaemia
  4. 4. AetiologyAetiology Laplace’s lowLaplace’s low (Tension varies directly with radius when(Tension varies directly with radius when pressure is constant)pressure is constant) – For every increase in the radius there is aFor every increase in the radius there is a large increase in tension, leading to furtherlarge increase in tension, leading to further enlargement of the aneurysmenlargement of the aneurysm
  5. 5. Rare causes of aneurysmsRare causes of aneurysms CongenitalCongenital – Marfan’s syndromeMarfan’s syndrome((misfolding of themisfolding of the protein fibrillin-1)protein fibrillin-1), Berry aneurysms, Berry aneurysms Post-stenoticPost-stenotic – Coarctation of the aorta, Cervical rib, Popliteal arteryCoarctation of the aorta, Cervical rib, Popliteal artery entrapment syndromeentrapment syndrome TraumaticTraumatic – Gunshot, stab wounds, arterial puncturesGunshot, stab wounds, arterial punctures InflammatoryInflammatory – Takayaso’s diseaseTakayaso’s disease(( is a form of largeis a form of large vessel granulomatous vasculitis with massive intimal fibrosis andvessel granulomatous vasculitis with massive intimal fibrosis and vascular narrowingvascular narrowing, Behcet’s disease, Behcet’s disease ((is a rare immune-is a rare immune- mediated small-vessel systemic vasculitis that often presentsmediated small-vessel systemic vasculitis that often presents with mucous membrane ulceration and ocular problems.with mucous membrane ulceration and ocular problems.
  6. 6. Rare causes of aneurysmsRare causes of aneurysms MycoticMycotic – Bacterial endocarditis, syphilisBacterial endocarditis, syphilis Pregnancy associatedPregnancy associated – Splenic, cerebral, aortic, renal, iliac &Splenic, cerebral, aortic, renal, iliac & coronarycoronary
  7. 7. Classification of aneurysmsClassification of aneurysms WallWall ■■ TrueTrue ■■ FalseFalse MorphologyMorphology ■■ Fusiform,Saccular,DissectingFusiform,Saccular,Dissecting AetiologyAetiology ■■ Atheromatous, Collagen disease,Traumatic,Atheromatous, Collagen disease,Traumatic, Mycotic (bacterial rather than fungal)Mycotic (bacterial rather than fungal)
  8. 8. ClassificationClassification FalseFalse is when there is a breach inis when there is a breach in the vessel wall such that bloodthe vessel wall such that blood leaks through the wall but isleaks through the wall but is contained by the adventitia orcontained by the adventitia or surrounding perivascular softsurrounding perivascular soft tissuetissue.. TrueTrue – Dilatation involving allDilatation involving all layers of the walllayers of the wall
  9. 9. FusiformFusiform – Spindle-shapedSpindle-shaped involving wholeinvolving whole circumferencecircumference SaccularSaccular – Small segment of wallSmall segment of wall ballooning due toballooning due to localized weaknesslocalized weakness
  10. 10. Incidence- atheroscleroticIncidence- atherosclerotic >90% affecting abdominal aorta>90% affecting abdominal aorta Infra-renal segment inInfra-renal segment in ~~95%95% Male : Female ratioMale : Female ratio 4:14:1 More common in western countriesMore common in western countries 5% over 50s, 15% over 80s5% over 50s, 15% over 80s Associated with iliac aneurysms in 30%Associated with iliac aneurysms in 30% Associated with popliteal aneurysms in 10%Associated with popliteal aneurysms in 10%
  11. 11. Classification of Thoracic Aortic AneurysmClassification of Thoracic Aortic Aneurysm
  12. 12. Anatomy of the abdominal aortaAnatomy of the abdominal aorta Begins at T12, Ends at L4Begins at T12, Ends at L4 Anterior relationsAnterior relations – Splenic vein, pancreas, duodenumSplenic vein, pancreas, duodenum RightRight – Cisterna chyli, IVC, azygos veinCisterna chyli, IVC, azygos vein LeftLeft – Sympathetic trunkSympathetic trunk Surface anatomySurface anatomy – Just above transpyloric plane in the mid line to a pointJust above transpyloric plane in the mid line to a point left to the midline on the supracristal planeleft to the midline on the supracristal plane
  13. 13. branches of the abdominal aortabranches of the abdominal aorta Paired visceral branchesPaired visceral branches – Suprarenal, renal, gonadalSuprarenal, renal, gonadal Unpaired visceral branchesUnpaired visceral branches – Coeliac, SMA, IMACoeliac, SMA, IMA Paired abdominal wall branchesPaired abdominal wall branches – Subcostal, inferior phrenic,lumberSubcostal, inferior phrenic,lumber
  14. 14. Clinical features of AAAClinical features of AAA Asymptomatic in 75%Asymptomatic in 75% – Incidentally discovered during clinical exam.orIncidentally discovered during clinical exam.or radiographic investigationradiographic investigation PainPain – Central abdominal radiating to the backCentral abdominal radiating to the back – Chronic due to stretching the vessel wall orChronic due to stretching the vessel wall or compression/erosion of surroundingcompression/erosion of surrounding structuresstructures – Acute pain due to ruptureAcute pain due to rupture
  15. 15. Clinical features of AAAClinical features of AAA RuptureRupture – Risk of rupture ~ aneurysm sizeRisk of rupture ~ aneurysm size – Retroperitoneal 80%, back pain, stableRetroperitoneal 80%, back pain, stable – Intraperitoneal 20%, abdo/back/falnk pain,Intraperitoneal 20%, abdo/back/falnk pain, shockshock – 5-year rupture rate 0% in AAA <5cm5-year rupture rate 0% in AAA <5cm – 5-year rupture rate 25% in AAA >5cm5-year rupture rate 25% in AAA >5cm Risk of rupture can be predicted byRisk of rupture can be predicted by – High diastolic BP, COADHigh diastolic BP, COAD
  16. 16. Complications of AAAComplications of AAA Fistulation, rareFistulation, rare – Gut, IVC, left renal veinGut, IVC, left renal vein Thrombosis, rareThrombosis, rare – Acute lower limb ischaemiaAcute lower limb ischaemia Distal embolismDistal embolism – Acute ischaemia to small distal areas (trashAcute ischaemia to small distal areas (trash foot)foot) Distal obliterationDistal obliteration – Claudication, rest pain, gangreneClaudication, rest pain, gangrene
  17. 17. InvestigationInvestigation CXR, PFTCXR, PFT ECG, EchoECG, Echo ESRESR U&EsU&Es USSUSS Spiral CT with contrastSpiral CT with contrast ArteriographyArteriography
  18. 18. CT ScanCT Scan Spiral CTSpiral CT
  19. 19. AngiographyAngiography
  20. 20. Indications for operation of AAAIndications for operation of AAA AsymptomaticAsymptomatic ■■ Aneurysm > 55 mm in APAneurysm > 55 mm in AP ■■ Patient fit for surgeryPatient fit for surgery ■■ Indications for endoluminal are the sameIndications for endoluminal are the same SymptomaticSymptomatic painful or tenderpainful or tender distal embolisationdistal embolisation
  21. 21. Management of AAAManagement of AAA Elective repair for AAA >6cmElective repair for AAA >6cm – Mortality 5%Mortality 5% Urgent repair for AAA <6cmUrgent repair for AAA <6cm – Developed back painDeveloped back pain – Rate of growth >0.5cm / 6 monthRate of growth >0.5cm / 6 month Emergency repair for ruptured AAAEmergency repair for ruptured AAA – Mortality 50%Mortality 50%
  22. 22. Elective surgical repairElective surgical repair 6-unit X-matched blood6-unit X-matched blood Mid line or transverse incisionMid line or transverse incision Aneurysm neck defined and controlledAneurysm neck defined and controlled Control of normal vessels distal to AAAControl of normal vessels distal to AAA Systemic heparinization, 5000IUSystemic heparinization, 5000IU AAA sac opened and thrombus removedAAA sac opened and thrombus removed Back bleeding from lumber arteries controlled byBack bleeding from lumber arteries controlled by suturessutures Inlay tube or trouser synthetic graftInlay tube or trouser synthetic graft Closure of aneurysm sac over graftClosure of aneurysm sac over graft
  23. 23. Emergency surgical repairEmergency surgical repair Unstable patient, no investigationUnstable patient, no investigation Stable patient, USS/spiral CTStable patient, USS/spiral CT 10-unit of x-matched blood10-unit of x-matched blood Urinary catheter & 2 large-bore i.v. linesUrinary catheter & 2 large-bore i.v. lines Resustation to systolic BPResustation to systolic BP ~100mmHg~100mmHg Crash anaesthetic inductionCrash anaesthetic induction No heparinizationNo heparinization Rapid entrance to abdomen & neck controlRapid entrance to abdomen & neck control – If difficult, supra-renal clamp for short periodIf difficult, supra-renal clamp for short period
  24. 24. Complications of aortic surgeryComplications of aortic surgery Haemorrhage, DICHaemorrhage, DIC CVACVA Colonic ischaemia spinal cord ischaemiaColonic ischaemia spinal cord ischaemia Aorto-enteric fistulaAorto-enteric fistula Graft thrombosisGraft thrombosis Myocardial ischaemiaMyocardial ischaemia Renal failure, ARDS, MODSRenal failure, ARDS, MODS False anastomotic aneurysmFalse anastomotic aneurysm Distal embolism (trash foot)Distal embolism (trash foot)
  25. 25. Endovascular repair of AAAEndovascular repair of AAA Patient unfit for surgical repairPatient unfit for surgical repair – severe cardio-pulmonary co-morbidities, hours shoesevere cardio-pulmonary co-morbidities, hours shoe kidney, Inflammatory AAA, hostile abdo.kidney, Inflammatory AAA, hostile abdo. Anatomical suitabilityAnatomical suitability – Neck diameter & lengthNeck diameter & length – Iliac arteries diameter & tortousityIliac arteries diameter & tortousity MorbidityMorbidity – Endoleak, migration, kink, thrombosisEndoleak, migration, kink, thrombosis MortalityMortality ~5%~5% Flow-up & durabilityFlow-up & durability
  26. 26. Inflammatory AAAInflammatory AAA Marked fibrosis of the aneurysm wall extending to theMarked fibrosis of the aneurysm wall extending to the surrounding structuressurrounding structures It involve the anterior and lateral aspects onlyIt involve the anterior and lateral aspects only It associated with inflammatory cell infiltrate of T- , B-It associated with inflammatory cell infiltrate of T- , B- lymphocytes & plasma cellslymphocytes & plasma cells The fibrosis may compress the ureters leading to renalThe fibrosis may compress the ureters leading to renal failurefailure Rupture is less common and usually posteriorRupture is less common and usually posterior Pt. presents with abdo. pain, weight loss, raised ESRPt. presents with abdo. pain, weight loss, raised ESR Difficult surgery, therefore conservative/endovascularDifficult surgery, therefore conservative/endovascular
  27. 27. popliteal aneurysmspopliteal aneurysms Second most common site of atheroscleroticSecond most common site of atherosclerotic aneurysms (70 % peripheral, 2/3 B/L)aneurysms (70 % peripheral, 2/3 B/L) C/FC/F – pulsatile swellingpulsatile swelling – aneurysm thrombosisaneurysm thrombosis oror distaldistal emboliemboli USS/CT/Arteriography to confirm diagnosisUSS/CT/Arteriography to confirm diagnosis 40% of pts with PA aneurysms have an AAA40% of pts with PA aneurysms have an AAA
  28. 28. IndicationIndication – ComplicationComplication – Asymptomatic Size > 25 mmAsymptomatic Size > 25 mm RxRx – Surgical repair, resection/ligation and veinSurgical repair, resection/ligation and vein bypassbypass
  29. 29. Femoral aneurysmsFemoral aneurysms Can occur in isolation but usually part ofCan occur in isolation but usually part of generalized arteriomegalygeneralized arteriomegaly Often symptomless and rarely ruptureOften symptomless and rarely rupture Distal emboli & thrombosis may occurDistal emboli & thrombosis may occur Surgical repair by using vein or synthetic graftSurgical repair by using vein or synthetic graft
  30. 30. Splenic aneurysmsSplenic aneurysms Male : female 1 : 4Male : female 1 : 4 It present in child bearing periodIt present in child bearing period Usually symptomless unless rupturedUsually symptomless unless ruptured Rupture rate 25% in the third trimesterRupture rate 25% in the third trimester Surgical treatment is indicated if theSurgical treatment is indicated if the aneurysm diameter >3cm or patient isaneurysm diameter >3cm or patient is pregnantpregnant
  31. 31. 1- AAA1- AAA A- is 4 time more common in malesA- is 4 time more common in males B- incidence is falling in western countriesB- incidence is falling in western countries C- may safely observed if asymptomatic andC- may safely observed if asymptomatic and >5.5cm in diameter>5.5cm in diameter D- is rarely amenable to endoluminal stentingD- is rarely amenable to endoluminal stenting E- is less common than popliteal aneurysmsE- is less common than popliteal aneurysms
  32. 32. 2- AAA2- AAA A- may cause embolisation to lower limbsA- may cause embolisation to lower limbs B- is more common in malesB- is more common in males C- can almost always be treated byC- can almost always be treated by endovascular stentingendovascular stenting D- can be detected by screeningD- can be detected by screening E- should be operated upon when it is 5.5 cmE- should be operated upon when it is 5.5 cm longlong
  33. 33. 3- AAA3- AAA A- typically rupture at 4cm diameterA- typically rupture at 4cm diameter B- extends above the renal artery in 20% ofB- extends above the renal artery in 20% of casescases C- is invariably visible on abdominal X-rayC- is invariably visible on abdominal X-ray D- is associated with coronary artery diseaseD- is associated with coronary artery disease E- has an association with smokingE- has an association with smoking
  34. 34. answersanswers 1- A1- A 2- ABD2- ABD 3- DE3- DE

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