This document provides an overview of aortic aneurysms. It begins with definitions and classifications of aneurysms based on location, morphology, and etiology. Abdominal aortic aneurysms are discussed in more detail, including risk factors, natural history if left untreated, methods of diagnosis using imaging modalities, and treatment options of open surgical repair versus endovascular repair. Complications of each treatment method are also summarized. The document aims to cover the historical aspects, epidemiology, pathophysiology, clinical presentation, diagnostic evaluation and management principles of aortic aneurysms.

1. AORTIC ANEURYSM
SURG LT CDR KHEM SAGAR PATEL
MODERATOR :LT COL V K SINGH

2. SCOPE
• INTRODUCTION
• HISTORICAL ASPECT
• CLASSIFICATION
• ABDOMINAL AORTIC ANEURYSM
• DECISION MAKING /APPROACH
• SURGICAL MANAGEMENT
OPEN REPAIR
ENDOVASCULAR REPAIR

3. INTRODUCTION
• The term ANEURYSM is derived from the Greek word ANEURYSMA
meaning “ a widening”.
• An ANEURYSM is defined as a permanent localized dilation of artery
having at least a 50 % increase in diameter compared with the
expected normal diameter.
• Normal arterial diameter is dependent on age, gender, body size and
other factors.
• ECTASIA- Arterial dilation less than 50% above normal.
• ARTERIOMEGALY– Diffuse arterial enlargement involving with an
increase in diameter greater than 50% above normal.

4. HISTORY
• 2000 B.C – PAPYRUS – Description of traumatic aneurysms of the
peripheral arteries.
• 1311 A.D – GALEN -- Defined an aneurysms as a localized pulsatile swelling
that disappeared on pressure.
• 1793 A.D – JOHN HUNTER -- Operated for a pulsatile mass in popliteal
fossa.
• 1950 A.D – ALEXIS CARREL/ DeBakey and Cooley – Demonstrated a
segment of aorta can be replaced by another artery or vein.
• 1953 A.D – BAHNSON– First successful repair of ruptured aortic aneurysm.
• 1954 A.D – ETHEREDGE– Repair of thoracoa-bdominal aneurysm .
• 1991A.D -- PARODI – Revolutionary minimally invasive endovascular
approach

5. ARTERIAL ANATOMY
• Intima -Endothelial cells
• Media- Smooth muscle cells,
collagen & elastin
• Adventitia -Collagen fibers

6. CLASSIFICATION
• True/False
• Etiology
• Morphology
• Location

7. TRUE/FALSE
• True aneurysm- contains all
layers of arterial wall.
• False/Pseudoaneurysm
aneurysm- dilation covered by
thick fibrinous capsule. Injury to
wall of vessel allows blood to
escape from vessel into adjacent
tissue . Extravasated blood
coagulates and becomes a mass
along side the vessel.

8. BASED ON LOCATION
LOCATION FREQUENCY
• ABDOMINAL AORTA 65%
• THORACIC AORTA 19%
• AA + ILIAC 13%
• THORACOABDOMINAL 2%
• ISOLATED ILIAC 1%
LOCATION-PERIPHERAL
LOCATION FREQUENCY
• POPLITEAL 70%
• FEMORAL together make up to
90%
• CAROTID 4 %
• SUBCLAVIAN 2%
• CEREBRAL 2%
• SPLENIC 1%
• MESENTRIC 0.5%
• RENAL 0.5%

9. BASED ON MORPHOLOGY
• FUSIFORM SYMMETRICAL -Circumferential enlargement involving all
layers of the artery wall.
• SACCULAR ANEURYSM - Affecting only part of the arterial
circumference
• DISSECTING-Tear in the wall of aorta and blood deposits in between
them.
• BERRY ANEURYSM- Weakness in the wall of cerebral arteries.

10. ABDOMONAL AORTA ANEURYSM

11. AAA
Morphological classification
• Fusiform Aneurysms
• Saccular Aneurysms
• Dissecting Aneurysms
Segments involved
• Thoracic
• Thoraco-abdominal
• Abdominal
• Main Branches Of The Aorta
• Iliac Arteries

12. Incidences
• Infra renal- most common
• Followed by descending

13. Risk Factors
• Familial History- 20% of patients with AAA have 1 st Degree relative
• Connective tissue disease
Marfan syndrome
Ehlers-Danlos syndrome
• Atherosclerosis (90%)
Smoking
Hyperlipidemia
Diabetes
• Gender - Males > Females
• Age

14. FACTORS INVOLVED
• ANATOMICAL
• MECHANICAL
• GENETICS
• BIOCHEMICAL
• IMMUNOLOGICAL

15. ANATOMICAL
• Gradual tapering of aorta and reduction of elastic lamellae in distal
aorta
• Reduction /absence of nutrient arteries in infra-renal aorta
• Wall stress is force exerted on the wall

16. BIOCHEMICAL
• The Biomechanical Perspective Hypothesis is a failure of the
aneurismal wall, when wall stresses exceeds wall strength.
• Elastin and elastolytic protease - elastin – mainly in media of the
arteries- insoluble -elastic recoil ability
• Collagen and collagenolytic proteases - structural unit is tropocollagen
-aortic collagen is concentrated in the adventitia - multiple cross links-
insoluble
• Degeneration of both occurs in AAA due to early activity of MMP III (
elastolytic protease and collagenolytic protease

17. MECHANICAL
• Ratio of elastin to collagen
• Collagen dominated or Elastin dominated
GENETIC
• Mutation in single gene- Marfan
• Specific variation in DNA (polymorphism)

18. AAA
Modified Crawford classification
• Type I – involves Descending thoracic aorta and abdominal aorta
proximal to renal arteries.
• Type II – Most of DTA + AA distal to renal arteries/common iliac
• Type III – Involves distal aorta and distal to renal arteries.
• Type IV – Involves distal to abdominal aorta.
• TypeV- Discending aorta and proximal to renal artery.

20. AAA Sequelae/ Natural history
• Gradual And / Or Sporadic Expansion
• Accumulation Of Mural Thrombus Complications
• Rupture
• Thromboembolic Events
• Compression Of Adjacent Structures

21. AAA RUPTURE & SURVIVAL
5 YEAR RUPTURE RATE
• 7.0cm or more 75%
• 6.0cm to 7.0cm 35%
• 5.0cm to 6.0cm 25%
SURVIVAL
• > 6.0CM 5YR SURVIVAL 6%
• < 6.0CM 5YR SURVIVAL 47.8%

22. CLINICAL PRESENTATION- AAA
• AAA are asymptomatic before rupture in 75%
• Abdominal palpation may show a pulsatile abdominal mass.
• Vague abdominal pain and back discomfort.
• Large aneurysms – GI symptoms– early satiety and vomiting.
• Inflammatory aneurysms- pain /fever
• comlications

23. Clinical Presentation, AAA-- RUPTURE
• Syncope
• Back abdominal pain
• Shock
• Sudden death
• Severe pain
• Cullen sign -periumbilical ecchymosis
• Grey-Turner sign- flank ecchymosis
• Hematemesis melena hematochezia

24. Diagnosis
• PHYSICAL EXAMINATION
-- Detection of expansile pulsation
-- unreliable about 50%-- false negative
-- large hypogastric aneurysm palpated on rectal examination
• INVESTIGATIONS
--X RAY
-- USG
-- CT/MRI / MR ANGIOGRAPHY
-- ARTERIOGRAPHY

25. X Ray
• X ray - lumbar spine radiograph
-Characteristic of eggshell
pattern calcification

26. USG
• Ultrasound is most useful and least
expensive mode of diagnosis.
• Measuring transverse aneurysmal
diameter.
• Screening /Surveillance/ follow up after
endovascular repair.
• Best used to assess progression of AAA
size.
• Cant detect Rupture.
• Sensitivity of ultrasound Ranges from
82% to 99% in cases with a pulsatile mass
• visualization of the aorta inadequate due
to obesity, bowel gas.

27. CT IMAGING
• Precise test – provides good
images of aorta, aortic lumen,
branch, vessels and adjacent
retroperitoneal structures.
• Shows size and extent of
aneurysm and relation to renal
and iliac arteries.
• SPIRAL CT – 3 dimensional
image

28. MRI/ MR ANGIOGRAPHY
• Use of contrast agents have made it possible to produce high quality
images of aorta.
• Useful for planning and follow up of endovascular repair.
• Less sensitive than CT scan in identifying accessory renal arteries.
• Less sensitive for detecting calcification.
• No use in case of metallic implants.

29. Evaluation and decision making
ACC guidelines(2014)- On the basis of recommendations and level of
evidence
• AAA measuring 5.5 cm or larger should under go repair to prevent
rupture.( class I, Evidence B)
• Size 4 to 5.4 cm should be monitored by usg/CT every 6 to 12 months
to detect expansion.(Class I, Evidence A)
• Clinical triad of abdominal pain , pulsatile mass, and hypotension-
surgical evaluation (class I, Evidence B)
• Symptomatic patient-Repair irrespective to size(Class I, Evidence C)

30. Decision making
• Open or endovascular repair for good surgical candidates (class I,
evidence A)
• Open repair who can,t comply with periodic long time follow up
(Class II a , evidence C)
• Endovascular repair for co existing pathology- cardiac or pulmonary (
class II b, Evidence B)

31. TREATMENT OPTIONS
• OPEN SURGERY(OSR) • ENDOVASCULAR (EVAR)

32. OPEN SURGICAL REPAIR -STEPS OF PROCEDURE
• Incision
• Exposure Of Aorta
• Exposure Of Iliac Arteries
• Site Of Distal Clamping
• Site Of Proximal Clamping
• Opening Of Aorta/ Incision Extended
• Insertion Of Graft
• Checking The Patency Of Graft
• Closure Of Sac Aaa

33. Open Repair

34. ENDOVASCULAR REPAIR(EVAR)
• A stent graft (a fabric tube supported by
metal wire stents that reinforces the weak
spot in the aorta) is inserted into the
aneurysm through small incisions in the groin.
• first inserts a catheter into an artery in the
groin (upper thigh) and threads it to the
aneurysm.
• using an x ray to see the artery, the surgeon
threads the graft (also called a stent graft)
into the aorta to the aneurysm.
• The graft is then expanded inside the aorta
and fastened in place to form a stable channel
for blood flow. The graft reinforces the
weakened section of the aorta to prevent the
aneurysm from rupturing.

35. ENDOVASCULAR REPAIR
• Benefits
• Reduced complications and mortality
• Decreased hospitalization
• Less systemic complications, same mortality
• Shorter respiratory support
• Decreased ICU and hospital stay
• Decreased blood loss

36. COMPLICATIONS
1) Injuries to arteries of access – Iliac/ Supra Renal
2) Embolization - micro – Renal Failure distal – Ischemia
3) Procedure related Groin hematoma, wound infection
4) Device related -Migration, detachment, rupture, stenosis, kinking,
endoleak
5)Graft occlusion
6)Graft infection
7)Endoleaks - Leak around proximal or distal attachment sites ,
Persistent flow in aneurysm sac , Incomplete exclusion .

37. Endoleaks

38. THANK YOU